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Full text of "Spirillum fever : synonyms : famine or relapsing fever as seen in western India"

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PURCHASED FROM THE INCOME OF THE 

SAMUEL WHEELER WYMAN 




SPIRILLUM FEVER 



Digitized by the Internet Archive 

in 2010 with funding from 

Open Knowledge Commons and Harvard Medical School 



http://www.archive.org/details/spirillumfeversyOOcart 



SPIRILLUM FEVER 



SYNONYMS 



FAMINE OR RELAPSING FEVER 



AS SEEN IN WESTERN INDIA 



(y 

H.VANDYKE CARTER, M.D.Lond. 

SURGEON-MAJOR l.M.D. 

SURGEON IN CHARGE OF THE GOCULDAS TEJPAL HOSPITAL, 

LATE OFFICIATING PRINCIPAL AND PROFESSOR OF iMEmCINE, GRANT COLLEGE, AND 

FIKST PHYSICIAN, JAMSETJEE JEJEKBHOV HOSPITAL, BOMBAY 




LONDON 

J. & A. CHURCHILL 

NEW BURLINGTON STREET 

1882 



/r^'^y^y/ 



r^ 







APR 2 1 1921 



PREFACE. 



The following data were collected at Bombay between April, 
1877, and March, 1880 ; and during this interval (which includes 
the height and decline of the late fever-epidemic) having been 
placed in executive or administrative charge of both local Native 
Hospitals, I had ample opportunity for clinical observation. 

Genuine famine or relapsing fever had not been previously 
recognised in Western India ; and early perceiving the sanitary 
importance of establishing its identity, I spared neither leisure 
nor effort to procure the materials needful for adequate diagnosis. 
Whilst well aware of the imperfections of the record ensuing, I 
have endeavoured to note and duly estimate the prominent 
points of this remarkable disease ; and to ensure accuracy, no 
instances are here analysed except as such by means of the 
microscope were demonstrated to belong to the spirillar infec- 
tion. Experience leads me to insist upon the desirability of 
careful examination of the blood, on all practicable occasions ; 
and upon its absolute necessity, in cases deviating from the 
average state. The spirillum fever of man, may not long retain 
its peculiar suitability for advanced clinical research ; but, as yet, 
it affords the best known data for fresh pathological inference. 

I had the benefit (if so it can be termed) of repeated per- 
sonal experience of this fever : unfortunately, the last of these 
attacks brought to a premature close som.e more recondite en- 
quiries I hoped to undertake. 



VI PREFACE. 

Amongst the many obligations I am under for collateral aid, 
should be mentioned the valued co-operation of my colleagues 
at the J, J. Hospital, both European and Native ; also the 
judicious suggestions of the late lamented Dr. Murchison, and 
of Dr. J. Burdon Sanderson ; and the generous friendliness of 
Dr. Ferdinand Cohn of Breslau, and Dr. Robert Koch (then of 
Wollstein) : besides other equally appreciated assistance later 
rendered at Geneva, Rome and London. 

Such references as time permitted to the recent literature of 
Relapsing fever, are embodied in the text ; they serve to com- 
plete the proof that the Spirillar infection is one and the same 
disease, in both East and West. 

A few parts of the following Chapters have already appeared 
in the Transactions of the Royal Medical and Chirurgical Society 
of London, and in those of the recent International Medical 
Congress. 

The two Appendices contain data supplementary to and 
illustrative of the main topic. 



CONTENTS, 



SECTION I. 

HISTORY OF THE EPIDEMIC. 

CKAPTBR PAGS 

I. History of Fever sickness in the Mofussil i 

II. History of the Fever epidemic in Bombay . . , . . 14 

SECTION II. 

CLINICAL HISTORY OF THE SPIRILLAR INFECTION. 

I.- Source and sum of Data . ....,, . 31 
II. Definition and Clinical Summary. Illustrative cases. . . 33 

III. General phenomena: prodromata, physiognomy, body- weight ; 

acme, crisis and lysis. Special symptoms : headache, pains, 
thirst, appetite, vomiting, sweats, sudamina ; the tongue and 
state of bowels. Heart, pulse, lungs ; liver, spleen, urine . 69 

IV. Description of the Pyrexia. Definitions. Normal tempei-ature 

and pulse. Abortive and relapsing series. Pj^rexia at succes- 
sive stages of ordinary spirillar disease ; comparisons of tem- 
perature and pulse. Variations of pyrexia at the successive 
stages and in fatal cases . . . . . . . .125 

V. Complications of spirillum fever. Secondary fever, affections 
of the nervous, respiratory, circulating and digestive systems, 
of the urinary organs ; abortion . . . . . .170 

VI. Antecedents and Sequelae 228 

VII. Clinical modifications of spirillum fever. Essential and in- 
cidental ; modifications from conjoined enteric, typhus and 
malarious fevers. Bilious typhus . . . . . .231 

VIII. Mortality of spirillum fever. General features — i. Death-rate. 
2. Date of Death. 3. Apparent cause of Death. 4. Mode. 
Detailed features. 5. Influence of Sex. 6. Age. 7. Season. 
8. Period of epidemic. 9. Social station. 10. Birthplace. 
II. Race. 12. Habits. 13. Previous disease. 14. Mental 
depression. 15. Bodily exhaustion . ..... 241 



Vlil CONTENTS, 



CHAPTER 



IX. Anatomical lesions. Introductory observations. Summary. 
Description of lesions. Lesions according to stage of fever : 
final remarks. Memorandum on European observations . 248 

X. Diagnosis. Recognition of Relapsing fever ; its identification ; 

its clinical discrimination ....... 300 

XI. Prognosis 321 

XII. Treatment 325 

SECTION III. 

PATHOLOGY OF SPIRILLUM FEVER. 

1. Aspects of the Blood, general and special. Methods of examina- 

tion. General description of the blood ; normal aspect ; 
appearances according to stage of disease. Detailed de- 
scription of blood-elements according to stage of disease. 
Account of the spirillum ........ 333 

II. Etiology of spirillum fever. Predisposing causes. Contagion . 369 

III. Nature of the Disease. Explanation of its essential relations, 

its characteristic symptoms, and its epidemiological conditions. 411 

Appendix A. i. Artificial production of spirillum fever in the Monkey. 

2. Some Culture-experiments 429 

Appendix B. Concurrent Fevers at Bombay. Cerebro-spinal menin- 
gitis. Typhus, Enteric fever. Ague, Remittent fever . . . 436 

Index .......... . . . . . 447 



ILLUSTRATIONS. 

Chart No. I. of Famine and Fever data 
Sphygmographic Pulse-tracings .... 

Skin-eruption ........ 

Correlated data of First Relapse, Charts II. and III.' 

Microscopic Appearances of the Blood, Lymph, Heart 

products ........ 

Temperature-charts. Plates IV. V. VI. and VII.} .. ., , 

Temperature-charts of the Monkey. Plate VIII. ^ • ' ■ ^r me ena 



muscle, Culture- 



30 
102 
194 
358 

368 



' By oversight numbered i and 2 respectively. 




SPIRILLUM FEVER 



SECTION I. 

HISTORY OF THE EPIDEMIC. 



CHAPTER I. 

history of fever sickness in the mofussil 
(country districts). 

Normal Data of Western India. — The Presidency is mainly inter- 
tropical, extending over 125,156 square miles, and having a population 
of about 17,000,000. Excluding the province of Sind, its major part 
lies coastward, and rarely suffers from want of rain ; but there is a large 
area of raised upland (known as the Deccan plain), where, as the country 
recedes from the western sea-line, the rainfall gradually diminishes from 
40 to 20 inches per annum, or less. It is here that the late famine 
occurred, the nine affected districts embracing a continuous area of 
54,355 square miles, with a population of 8,000,000 ; of these, however, 
only five suffered severely, viz. Sattara (a part), Belgaum, Dharwar, and 
especially the more easterly sections of Sholapore and Kulladghi; the 
whole lie between N. latitude 14° and 18°, and have an area of 33,873 
square miles, with a population of 5,000,000, or about 147 individuals 
to the square mile. Here the soil is mostly shallow, and derived from 
trappean rock ; tree vegetation is sparse, and the incipient rivers com- 
paratively small. Cultivation in this semi-torrid region chiefly depends 
upon rainfall, which, in proportion as it decreases is also apt to fluctuate 
in amount and distribution ; the result being an annual liability to varia- 
tion in the harvest supply. Particularly is the meteorology of the last 
named eastern districts worthy of attention, owing to their position upon 
a nearly vertical line where the two alternate monsoons of peninsular 
India may be said to meet and subside ; and either rainy season failing 
the land must suffer. Mean temperature of air 75° to 80° F., mean 



*vU 



2 SPIRILLUM FEVER. 

monthly range 60° to 90°, or wider ; mean humidity of year about '60, 
monthly mean "45 to "86, the minimum often less ; barometric pressure 
27-5 in., the mean elevation being about 2,000 feet above sea-level. 

The inhabitants of the affected districts are mostly Hindoo Marattas, 
other races and Mussulmans being found to the east and south. A very 
small proportion of the Hindoos are strict vegetarians, but animal food 
is nowhere largely consumed. The great majority of the people are 
agriculturists, the remainder consisting of village officials, menials, and 
petty traders ; there are few large landholders or manufacturers on a 
wide scale, or populous towns ; and as but one line of rail exists, tran- 
sport is mainly effected by bullock-cart and pack-animals. The popula- 
tion is habitually too poor to store either food or money; and marriage 
being religiously inculcated, families abound. The common buildings 
are of clay, seldom of brick, not raised, and usually crowded ; regular 
village or house drainage is unknown, and the water supply rarely 
selected The people, however, are not deficient in comfort and intel- 
ligence ; they are industrious and abstemious, and preserve strict social 
discipline. 

In average years the population is not unhealthy, and it tends rather 
to increase; the normal death-rate may be not more than 25 per mille 
per annunx The prevalent disease is ' fever ; ' ' small-pox ' and 
' cholera ' are nearly endemic ; ' bowel complaints ' are common ; under 
these four heads, together with 'injuries' and 'other causes,' all the 
deaths are registered according to a plan now several years in operation, 
under native unprofessional agency. The returns are supervised by the 
Sanitary Commissioner and his assistants, who are commissioned medical 
officers. 

A'bnormal Events in the Decean Famine Districts. — The localities 
named above were free from distress and unusual disease, until the 
abrupt climatic derangements of 1876-77 ; and thence followed in suc- 
cession drought, dearth, and disease. In the first of these years the 
rainfall, beginning as usual in June ceased generally in August, or long 
before the crops were grown ; and in 1877, the same rainy season 
(S. W. monsoon) was early interrupted, not until the autumn being sup- 
plemented by the N. K monsoon ; so that for a second time the chief grain 
harvests almost totally failed, the loss being such as could not be at 
once made up even with good years. After September 1877, heavy rain 
fell, but where not excessive, it was of little immediate avail ; and the 
subsequent seasons of both 1878 and 1879, proved to be not particularly 
favourable. The resulting scarcity was especially felt in Sholapore and 
KuUadghi, where the total rainfall in 1876 had been only 6-19 inches 
and 476 inches respectively, or no more than one-fourth to one-sixth 
of the normal yearly mean ; hence here total failure of grain crops, 
earliest and greatest distress, and the maximum fever mortality. Similar 
contingencies, in like order, simultaneously ensued in the other districts 
named. In 1877, the general experience was of the same kind and local 
distribution ; and it was partially repeated during the spring and summer 
of 1878 and 1879. 

Course of Distress, 1876. — As early as August apprehensions of 
scarcity were expressed, and prices of the staple grains began to rise ; 



EPIDEMIC IN DISTRICTS. 3 

soon afterwards relief works were established by Government in suitable 
localities, and by the close of November upwards of 150,000 labourers 
were collected together. Food was at famine rates, and in some places 
could hardly be procured at all ; much of that offered for sale being old, 
and of bad quality. As pasturage and agricultural operations, with other 
sources of remunerative labour, ceased to be available, emigration began 
on a large scale ; and about the end of the year, 13 per cent, of the 
affected populations had left their homes. 

1877. — This year witnessed the severest sufferings, and descriptions 
have been published by eye-witnesses of the prevalent distress, in terms 
which it would be difficult to surpass. Cattle died of starvation, and 
the fields went untilled ; there was no food but what was imported, and 
every sort of edible plant was consumed ; even water to drink was often 
scarce. The aspect of the parched land in the eastern areas was com- 
pared to that of a desert, with a sky of gloom. Houses or whole 
villages were abandoned, and cherished personal ornaments were given 
up for coinage in large quantities by the better class of ryots. Migra- 
tions further extended ; but many of the infirm, poorer, and low caste 
would not leave their houses, though confronted with the prospect of 
death from privation. Whilst facilities for the importation of grain, with 
means of direct public aid, were liberally afforded by the authorities, and 
private charity abounded, yet it would seem impossible to concur in the 
view that at this time only a few persons died of actual want ; and how 
many thousands of all ages sank under the consequences of prolonged 
starvation, has never been adequately estimated. 

As the best available gauge of public distress, I have introduced into 
the appended Chart, No. i, the statistics of Government relief works 
(Column A). In general there was a gradual increase of applicants for 
aid from November 1876 (beginning with 98,422) until June 1877, when 
the maximum was reached of 529,951, or about 10 per cent, of the 
entire population of the five worst districts ; after this date, in prospect 
of the usual rains, the people were encouraged to return to their villages, 
and the works were closed in the ensuing November. 

1878.— Distress augmenting in the spring, relief works were again 
opened ; the rainy season began late, and the fever mortality continued 
to be excessive, pursuing the course shown in column B, under this 
date. 

1879. — Distress was again prevalent before seed-time in the South 
Deccan and elsewhere {e.g. in Kattiawar) ; ' deficient harvest owing to 
excessive and unseasonable rain, high prices, and the injury done to the 
later crops by locusts, grubs, and rats, all combined to bring about the 
recurrence of this calamity' ('Admin. Rep. of Bom. Gov.,' 1878-79). 

Sickness and Mortality, 1876.— At the close of this year the deaths 
from fever were beginning to augment : see the Chart, Column B. 

1877.— It is recorded that total deaths in the Presidency this year 
were 627,708, or 259,448 (41-3 per cent.) in excess of those of the pre- 
vious year — a remarkable augmentation, which was mainly due to 
' fever ; ' the mortality under that head amounting to 336,865, or 1 16,032 
in excess of 1876. Of this surplus 106,818 (upwards of 90 per cent.) 
pertained exclusively to the nine famine districts under notice, there 



4 SPIRILLUM FEVER. 

being elsewhere no such excess ; within the affected area the fever 
deaths were 223,388, indicating a rate of decease per mille under 
this head double the mean, i.e. 28-4 as contrasted with 14 per mille ; 
and in the two worst districts the rise of fever mortality was even 
higher, viz. from normal means of 13-1 and 11-4 per mille to 40*4 and 
50-5 per mille respectively. In the most easterly and poverty-stricken 
area of Kulladghi, where 9,757 persons died of fever in 1876, no fewer 
than 41,248 died from the same cause in the succeeding year ; and this 
after a large emigration of families. 

I should here remark that amongst the 49,187 deaths occurring in 
the several Relief-establishments, the casualties from ' fever ' not being 
discriminated, could not be included above ; I note, however, that a 
disproportionate part of these inclusive deaths (viz. more than one-fourth) 
occurred in the same district of Kulladghi alone. 

On comparing columns A and B, it would appear that the fever 
mortality did not rise so promptly as the public distress, lagging some- 
what behind, as it were ; this might, indeed, be anticipated, yet it should 
be remembered there was a large emigration of people early in 1877, and 
a partial return of the same after June, when deaths soon became more 
numerous. A similar correspondence of fever mortality with move- 
ments of the population, is noticeable in the following year ; and more 
emphatically was it established in Bombay city, during the chief famine 
year. 

Striking as are these statistics, they do not show the entire loss of 
life referable to dearth -fever ; for besides the hundreds of migrating 
villagers dying far from home, account should be taken of the many 
casualties everywhere due to the sequelae of fever, yet not included 
under the same heading. The official tables are necessarily silent re- 
garding the amount of sickness not fatal ; applying, however, my data 
from the Bombay hospitals, it might be said that for every fever-death 
above the mean, ten persons were ill. 

Lastly, I note that, whilst the high death-rate of the famine districts 
was due mainly to fever, yet ' Cholera ' (asserted to be veritable), ' Small- 
pox,' and * Injuries ' are returned as being unusually fatal ; moreover, 
there was an excess of deaths beyond the mean, amounting to 26,012 
from ' Bowel complaints,' and 68,460 from ' Other causes.' Assuming 
that the three first-named headings had no essential connection with the 
dearth, it may be supposed that under ' bowel complaints ' would come 
famine-diarrhcea or dysentery, so widely fatal during 1877 in the adjoin- 
ing impoverished areas of Madras. I find, indeed, that upwards of one-half 
the total deaths from bowel complaints in the whole Bombay Presidency, 
took place in the five worst famine districts alone ; or a number higher 
than the total for the Presidency during any year since 1868. Particu- 
larly in Kulladghi did the deaths from bowel complaints rise, viz. from 
1,402 to 6,102 — a proportional augmentation exceeding that of even the 
fever mortality there ; and in all the affected districts the main increase 
from this cause occurred strictly within the famine period, or contempora- 
neously with the increase from fever. It has been conjectured that the 
term ' Other causes ' — embracing so considerable an excess — did this year 
include ' privation ' or starvation in its acute and chronic forms (under 
the latter head coming exhaustion, atrophy, ansemia, scurvy, dropsy) ; 



EPIDEMIC IN DISTRICTS. 



■5 



some such adjustment seems needed, but in the absence of information 
recorded when events were transpiring, discussion becomes futile. 

1878. — Concurrent with existing distress was a continued high fever 
mortality, the year-deaths amounting to 201,418, or upwards of 70 per 
cent, beyond the mean; it rose considerably soon after the rains set in. 
The distribution of surplus deaths this year underwent a remarkable 
change; for whilst the excess in the South Deccan declined, yet in the 
North districts, where the famine had not been very severely felt, there 
was now a considerable augmentation. I could not understand how 
this radiation of fever mortality was produced, but such a transporting 
of infection as occurred in the direction of Bombay was here, too, 
possible and would account for the phenomenon ; it was demonstrated 
that spirillum or famine-fever existed in the Deccan during this year, at 
Sholapore. (See below.) 

1879. — Want still prevailing in the areas lately most affected, the 
fever mortality did not persist {inde Chart, Column B); and it is expressly 
stated, as regards the Sholapore district, that fever hardly seemed ' more 
frequent among the very emaciated than among those in better con- 
dition.' ^ The official records indicate at this date an experience re- 
sembling that of the famine period in Madras, in the greater prevalence 
of such diseases as ulcers, stomatitis, dropsy, dysentery, and diarrhoea ; 
and the mortality rate seems to have been often very high. With this 
subsidence of fever mortality where much distress and other sickness 
continued, I again observe that in some areas adjoining there occurred, 
on the other hand, a striking augmentation of deaths from ' fever ' ; thus, 
in the Concan and Gujerat proper the increase was very great, and in 
the absence of any allusion to coincident increase of malaria, it is open 
to conjecture whether or not the hunger-pest of 1877-78, whilst subsid- 
ing at its centre of origin, had spread to districts around. 

TABLE I. 



Summary of Column B. 




Year 


Fever deaths 


Totals 


Excessive mortality in famine years 


Normal f 
years \ 

Famine f 
years \ 


1875 
1876 

1877 
1878 
1879 


119,910"! 
116,570/ 
223,388 \ 

20i,4i8j 
129,840 


236,480 
424,806 


\ 188,326 



Memorandum on the contemporary state of Provinces ad- 
joining THE FAMINE DISTRICTS OF BoMBAY. — Within Presidency limits, 
the effects of the local dearth were extended (as would appear) only by 
migration of individual sufferers ; and of such diffusion the instance of 

1 Quoted from Dr. Mackellar's memorandum in the Report Sanitary Commiss., Bom- 
bay, 1879, where it is added that ' circumstances did not permit of observations exact 
enough to make a statement about any pecuharity in the sequence of attacks. ' In future, 
it may be understood that an adequate use of the cUnical thermometer and microscope, 
for even a brief period, is often sufficient to estabhsh the diagnosis of a new fever ; but 
nothing short of this may suffice. 



SPIRILLUM FEVER. 

Bombay city is a remarkable illustration : there may have occurred others 
like it In the nearer native states, however, towards both east and 
west, equal dearth and sickness prevailed, from the same climatic causes, 
during 1877. Thus, in Mysore, the total reported mortality of 1876 being 
54,265, during the first five months only of the following year it amounted 
to 85,915 — an enormous augmentation, due chiefly to so-called 'cholera,' 
the fever mortality (deaths 12,871) then also rising. Further data were 
not accessible, nor have I yet learned any particulars respecting the 
state of the conterminous Nizam's territory. Westward, the Kattiawar 
peninsula of Gujerat was nearly equally afflicted with drought and fever ; 
and thence was a nearly continuous stream of immigration to Bombay. 

With regard to certain districts of the Madras Presidency, not far 
separated from the worst affected in the Deccan, and like them suffering 
severely from deficiency of N.E. monsoon rains in the autumn of 1876 ; 
it is recorded by the Sanitary Commissioner that whilst the mortality 
from famine-diarrhoea was very great in the early part of 1877, yet at 
this time {i.e. when the fever mortality was so high in Bombay districts 
and city) no cases were anywhere seen resembling famine-fever, and 
that the famine people in Madras did not show symptoms of fever of 
any kind. 

Whence it seems that within an area, wide but continuous and 
uniformly afflicted, on the one side of a conventional mid-line (viz. the 
western) a fatal form of fever was very rife, whilst upon the other side 
{i.e. the eastern) such disease was absent. Here a positive datum being 
confronted by a negative one, the position amounts to discrepancy 
rather than contradiction. It is yet very perplexing, however viewed ; 
and, assuming the general accuracy of official statistics, I cannot conceive 
any reconciling term as regards the western area, except the supposition 
that famine-fever had been first introduced into the Deccan from Bom- 
bay, and did not spread beyond Presidency limits. Such an idea is 
inconsistent with recorded dates and places of fever mortality, yet I 
would not reject it were there any valid evidence in its favour. 

In detail, evidence is furnished by the Reports of the Sanitary Com- 
missioner of Madras that the fever mortality of the most affected districts 
did not subside during 1876, and it was there doubled in 1877. During 
1878 it was still undoubtedly high. From the Report of 1879 it seemed 
still in excess of the average previous to the famine, the statistics given 
showing that since 1866 the fever mortality in those districts, and in 
them alone, had augmented as much as in the Bombay famine area. It 
is understood that the fever was still of malarious origin : yet as regards 
one district, that of Chingleput, it is noticed ' that there is great ten- 
dency when the periodic attacks have once been established, for them 
to recur at intervals of a week or fourteen days ; the fever seemed to be 
contagious.' Such a statement appears to me suggestive of other than 
miasmatic fever, and were particulars admissible in official Reports, 
further information would have been of interest. 

Appreciation of Events in the Mofussil.— Owing to the absence of 
definite information in accessible records, one has to rely chiefly upon 
data collected in Bombay, and partly upon rational inference and 
analogy. 



EPIDEMIC IN DISTRICTS. 7 

The term ' fever ' in the Mofussil returns is held to mean {a) mala- 
rious remittents, and {b) pyrexia symptomatic of local irritation or in- 
flammation. Admittedly its application is very ill defined ; yet in the 
absence here of the ' continued ' fevers of Europe, and in the very 
probable rareness of acute local disease independent of malarious in- 
fluence, the employment of this word for fatal febrile sickness seems 
hardly more inexact than the current use of the expression ' remittent 
fever, ' 

Normal years {vide Chart No. i_, col. B, 1875-76). — The rise of 
fever mortality in and after the rains is comprehensible on the supposi- 
tion that malaria then more abounds, and its persistence in the succeed- 
ing cold and hot seasons of the year may point to local diseases of the 
head, chest and abdomen {e.g. cerebral congestion, bronchitis, pneu- 
monia, hepatitis, splenitis), variously attributable to climatic changes, 
age, sex, and hardships, especially in the subjects of malarial cachexia, 
A previous long residence in the Deccan does not enable me to add 
more, than that precise data respecting ' country fever ' are needed at 
the present day as much as ever. 

Fanmie years (col. B, 1877-78). — The old forms continuing in use 
it was impossible that any new febrile disease, even if present, could 
have been specified ; nor to meet the requirements of a grave sanitary 
crisis, were fresh medical terms introduced. There remains, therefore, 
to search for indications in the available data, and by suitable arrange- 
ment of these the Chart becomes more than suggestive. Thus, it shows 
that prior to the famine was no unusual fever sickness, and that with 
dearth the mortality rose so promptly as to indicate clearly a direct re- 
lationship : throughout, too, it was evident that the surplus death-rate 
could not be a simple exaggeration of the previous normal state, but was 
more likely due to a superadded disease. This new sickness did not 
seem attributable to intensified malaria, because it began during an 
unusually dry season, at the end of the rainless autumn of 1876, and 
long before the scanty rainfall of June 1877 ; ' and had there been present 

1 At Kulladghi the rainfall, in 1875, was 25-51 inches and chiefly autumnal ; the fever 
mortality greatest from August to October (mean monthly deaths 1,000 with narrow range) 
and least in February (562). In 1876 the rainfall was only 476 inches, and solely estival, 
yet the deaths from ' fever ' did not diminish as they should have, upon the hypothesis of 
contingent malarious influence ; and further, in spite of emigration and the continued ab- 
sence of rain, they continued to increase throughout the first six months of 1877, rising 
from 948 to 3,776 in July, when only 5-3 inches of rain had fallen, or not more than the 
mean to date. During the corresponding period of the previous normal year, the rise was 
705 to 953 ; and in no earlier record of these dates do I find any augmentation of fever- 
deaths comparable to that of 1877. In the first eight months of the chief famine-year, 
with moderate rain, the deaths were 13,450 in excess of the same period of 1875 (normal 
year) ; and as regards the dates from September to December, the large increase of 19,517 
fever-deaths beyond the mean seems hardly exphcable by a distributed rainfall of 18 65 
inches, even after making widest allowance for the debilitating effects of want ; indeed, 
the more reasonable supposition wt)uld be that malaria had then co-operated with pre- 
existing causes of disease, rather than itself become the main cause. 

In an adjoining coast district unaffected by drought, the deaths from fever rose, with 
a nearly identical rainfall, to 10,662 in 1877, as compared with 6,452 in 1876 ; and this 
augmented mortality was attributed to the effects of malaria upon famine immigrants 
seeking relief in Kanara, Yet if this were so, how is it that the mortality began with im- 
migration before any rain had fallen ? In March (a dry month) there were 836 fever- 
deaths in 1877, as contrasted with 518 during the same month of the previous normal year. 

In these notes I assume the ordinary theory of malaria to be borne in mind ; com- 
bined heat and moisture being the shie qua non of miasm-production. It is also presumed 
that the natural history of famine-fever is remembered. 



8 SPIRILLUM FEVER. 

any time during this period even the ordinary degree of miasmatic in- 
fluence, it is difficult to suppose that the death-rate would have continued, 
to rise with increasing aridity of the soil. It is true that public distress 
was then augmenting, yet I am not aware that the destitute are specially 
susceptible to malarious influence, or likely to die therefrom in propor- 
tion to their destitution. Still, were this so, the difficulty remains of 
accounting for so large a mortality when miasm-production was at a 
minimum. That the increasing mortality in the hot season of 1877 was 
due to local inflammations, is an idea nowhere advanced ; and besides, 
local complications occur in fatal famine-fever nearly as often as in fatal 
remittents, pneumonia (e.g.) being much the commonest in both infections. 

After the rainfall of September severe malarious remittents possibly 
prevailed in the Bombay famine districts, as they are reported to have 
supervened in those of Madras ; and persons enfeebled by want may 
have suffered unusually therefrom, with the result of an augmented 
mortality. At the same time, the public distress did not subside or at 
once diminish with the advent of rain ; on the contrary, it persisted, and 
the population of the districts becoming augmented by immigrants 
returning in hopes of a favourable season, which did not arrive, there 
were then more subjects liable to all forms of disease. 

1878. — Though the number of casualties diminished, and their dis- 
tribution in time of necessity was more uniform, yet the proportionate 
loss of life may have been hardly less than in the previous year. There 
is no better indication of malarial exacerbation, and the presence of 
spirillum fever was demonstrated at a chief famine centre. 

1879. — The striking diminution of fever sickness and mortality with 
the advent of this year (when also they became less frequent in Bombay 
town and hospitals — vide Chart, Cols. B, C, D) points to some particular 
influence, which I must assume to be that of epidemic decline within 
primary areas. Much public privation certainly persisted, but the stress 
of infection subsided ; and, as intimated a few pages back, it may have 
spread centrifugally to adjoining areas free of want. Depending upon 
the official returns, I see here signs of the course of disease corresponding, 
in great measure, to known epidemic laws. 

Evidence fro7n Analogy. — The malaria hypothesis not satisfactorily 
accounting for the late excessive sickness, experience of dearths in 
Europe or elsewhere might furnish the required explanation ; and here 
the analogical inference becomes clear, being to the effect that contem- 
porarily with distress in the Deccan there may have arisen a febrile 
epidemic disease, not malarious, but comparable to the famine-fever of 
other countries. An undefined pyrexia attendant on the last stages of 
privation, has been mentioned in this connection : what it could be was 
worth testing. Fatal spirillum fever was highly variable in its manifes- 
tations at Bombay, and often by no means corresponded with descriptions 
in medical text-books. 

Direct Evidence. — It might seem impossible that non-resident en- 
quirers could learn the true character of a comparatively fugacious com- 
plaint like relapsing fever, especially when separated from the nearer 
seats of the disease by a distance of 200 miles or more. Yet the obstacles 



EPIDEMIC IN DISTRICTS. 9 

to proof are not insuperable, the following contingencies being possible : 
a. A Deccan resident while affected with ' fever ' might be brought in 
a few hours by rail to Bombay, and be at once admitted into hospital 
and be examined, b. The verbal testimony of patients showing specific 
fever might be accepted as to the date and place at which their sickness 
arose, c. Specimens of blood taken from 'fever' subjects resident in 
the Deccan, might be preserved and scrutinised at the Presidency town. 
As only by accident were new comers brought to hospitals or early came 
of their own accord, instances like those under a and b would necessarily 
be very rare ; and I consider it fortunate that there are any of the kiiad 
to be met with. The following cases, therefore, bear a significance 
which is not to be measured by their numbers. I regret that blood- 
specimens were not earlier procured from the Mofussil, but was not 
aware how to prepare them until the height of the epidemic had passed. 

Proof under a. Case I. — J. F. H., aet. 35, Mussulmanin, female domestic, was 
brought to hospital by the police on May 30, 1877, from the adjoining railway-station 
of Byculla, where she was found to be in a state of delirium : ' a friend with her 
states she has been suffering from fever for eleven days while at Poona (Deccan) ; she 
arrived at Bombay this morning to go to her brother's house, but became delirious, 
and the friend not knowing where to take her to, reported her condition to the police ' 
(quotation from original notes of case). On admission the axillary temperature was 
102°, pulse 120, feeble, respirations 25, shallow ; tongue dry, furred, brown ; thirst 
excessive, cough and sibilant rales in chest ; next day, the blood was thus described 
by Dr. A. — coagulation slow, plasma clear, plasmic bodies a few, white corpuscles 
many, spirilla seen. With prompt subsidence of the fever immediately following, 
jaundice and hepatic uneasiness were marked ; she remained free from fever for nine 
days, when a pronounced relapse took place, lasting four days, on three of which the 
blood-spirillum was again found. Jaundice and delirium also returned ; there was a 
prompt fall of temperature preceded by the perturbatio critica, and much exhaustion 
subsequently. She remained in hospital eleven days longer, and then left in a con- 
valescent state. 

I saw this woman frequently, and at the time noted there was no 
reason to doubt the truth of her history. How she acquired relapsing 
fever at Poona is unknown ; it may have been by contagion. The case 
further shows that residents in the chief Mofussil town were in the way 
of catching the disease so early as May 1877. This is similar to expe- 
rience in Bombay. 

Evidence under b. CASE II. — B. K., set. 20, country lad, Hindoo, immigrant 
from the Deccan, destitute but not starving, was admitted on April 30, 1877. His- 
toi-y — had tramped from Poona in search of work and food ; was seized with fever 
above the Ghats (eighty or ninety miles by road from Bombay), and resting two days, 
descended to Thanna (twenty miles off), again rested one day, and then walked to 
Bombay, when he was so ill that the day after his arrival he came to hospital, and was 
admitted into my clinical ward. At this date seven days had elapsed, according to 
his plain and repeated statement, since the fever began, five of which had been spent 
on the road ; when seen on the evening of day of admission, he presented several 
usual symptoms of the new fever — temp. 104°, pulse 108, small and soft, respirations 
28 ; bronzed fades, coated tongue, frontal headache, nausea, hepatic fulness and 
tenderness, jaundice, some cough, pains in the bones of the lower limbs, but spleen 
not visibly enlarged ; the blood was found by me to contain many active spirilla. 
Next day a marked crisis occurred, the temp, falling 8° F. , then a rebound to the 
normal temp. , and, excepting dysenteric diarrhoea with much debility, no interruption 
to convalescence; discharged May 31. 

A common typical case of spirillum fever seen late, with no indica- 
tion of relapse except some periodic splenic fulness \ the absence of a 



lO SPIRILLUM FEVER. 

febrile recurrence not, however, impairing the patient's testimony in any 
degree. Date of immigration about the height of the Bombay epidemic, 
when crowds of immigrants were arriving. 

I took occasion to point out to my class of students, the great pro- 
babiUty that this lad's fever had been contracted on the road or possibly 
in his village home, his long journey on foot not, according to my obser- 
vation in Bombay, militating against this view ; and the whole case, like 
that of the woman above, affords an illustration not only of spirillum 
fever prevalent in the interior, but also of its direct conveyance to the 
Presidency, where it might spread. 

Case III. — F. R., set. 23, Christian half-caste, carpenter, resident at Madras; set 
out thence on foot for Bomljay ; he was at Poona about a week ago (close of July 
1877) and had fever ; leaving he had chills and renewed fever on the road ; arrived in 
Bombay yesterday evening (31st), coming straight to hospital ; then temp. I04'^'4, pulse 
128. August I —Pyrexia, dry skin, headache, pains, bilious vomiting, jaundice, con- 
stipation ; blood examined on admission and also this morning ; the spirillum found, 
though sparingly (Mr. S. A.), and again found in the evening, when the temp, rose to 
i04°-8, next day declining to 97°, by critical fall ; much weakness ; discharged after 
three days at his own request. 

It could not be said whether or not this specific attack was the first, 
for the man asserted that he had been suffering from ' ague ' for a month 
previously ; and if his statement were true, it in no way invalidates the 
significance of the case as one of specific fever acquired in the Mofussil, 
but would also serve to show that particular means are needed to dis- 
tinguish this peculiar form of pyrexia, which otherwise might not be 
recognised. Neither of the temperature-charts of these two cases, nor of 
No. 4 below, is in the least degree characteristic of ordinary relapsing 
fever ; but, on the contrary, to an observer without practical experience of 
spirillum fever, the charts would seem absolutely insignificant, as they 
show only the last 1-3 days of fever, followed by an apyrexial state. 

Case IV. — M. B. , set. 35, Hindoo, ill-fed and anaemic, admitted with fever in*o 
the J. J. Hospital, July 2, 1877; he gives the following history. Left his native 
place in the Kurar Petta (famine district of Satara) twenty days ago in consequence 
of want of food, travelled on foot to Bombay and arrived here four days ago, putting 
up at Oomerkari, had fever on arrival in the town and now comes to hospital ; on 
admission was very ill, temp. io5°"6, pulse 120 ; the pyrexia remitted on two days and 
on the third subsided by crisis, the temp, sinking to 96° '4, pulse 95 ; there was some 
secondary fever with diarrhoea, and later on two isolated paroxysms which might re- 
present the rela]5se. The blood was examined on the day of his entering hospital 
and on the next day also, the characteristic parasite being found on both occasions ; 
it was not seen after the critical fall of fever. 

Here, again, supposing that reliance can be placed upon the simple 
statement of the patient that he had been in Bombay only four days, 
the clinical evidence would emphatically point to the conclusion that 
the specific fever exhibited by this man had been contracted before his 
arrival in the town. I have no hesitation in making this assertion, for 
whatever doubts be suggested as to the previous duration of his fever, 
the fact remains that in accordance with large clinical and experimental 
experience, the incubation period of the disease would necessarily carry 
back the date of infection prior to the man's arrival. Were his attack 
a 'relapse,' the inference of extra-mural origin of the disease would be 
still more strengthened. 



EPIDEMIC IN DISTRICTS. 1 1 

There are before me the notes of several other instances of demon- 
strated spirillum fever dating back to day of arrival in Bombay, or to 
one or two days afterwards ; and in my own opinion these, too, were 
valid evidence of the point in question, for no data are known to me 
tending to show that, amongst men, the contagion of this fever is capable 
of operating instantaneously in the production of pyrexia. On the contrary, 
in the remarkable series of six instances of infection by inoculation at 
autopsis of fever patients, which is detailed in the chapter on ' Contagion,' 
the periods of incubation were as follows : — 3 days 14 hours, 3 days or 
possibly 4 days, 7 days, 7 days, 7 days 4 hours, 7 days 4^ hours ; mean 
of the series, 6 days. As under ordinary conditions contagion is not 
likely to operate more quickly than by way of inoculation, it may be 
assumed these dates are not excessively long ; and therefore any attack 
of fever supervening a day 01 two after an immigrant's arrival in Bombay, 
had almost certainly been contracted outside the town. 

It may also be stated here that relapsing fever is communicable at all 
times when the blood contains the characteristic bacteriiwi — namely, 
during fever of invasion-attack (mean duration in man, 7-8 days), of 
first relapse (mean duration, 4-5 days), and even of second relapse 
(mean duration, 2-3 days), or for a total of about fifteen days in the 
course of a prolonged illness. But these febrile periods are separated by 
apyretic intervals of about seven and nine days respectively, and there- 
fore the whole time over which possibility of active manifestation of 
disease extends (and with this the faculty of propagation) becomes 
enlarged to thirty days or so ; which is a term long enough for any 
journey a famine immigrant would make in traversing the country from 
his native town or village to the Presidency, inclusive of due intervals 
of rest en route. No allusion is here made to the fact that the fever is 
communicable during an additional period, corresponding to the few 
days immediately preceding visible pyrexia. 

Lastl)'^, I remark that a band of famine immigrants once infected 
might not only convey their fever weeks together amongst themselves, 
thus allowing of even long sea voyages becoming the means of trans- 
porting famine-fever ; but by its propagation from their members to 
strangers coming into contact with the band, a still more prolonged 
manifestation of the disease becomes not only possible, but quite pro- 
bable. In fact, thus do epidemics arise ; and hence the great significance 
of the few cases I have now narrated, for it is evident that, famine-fever 
once appearing in the Mofussil, widespread sickness was at least likely.' 

' Amongst the many other confirmative data in hand, the following may be useful in 
this place : — a. It was matter of common observation to myself and other medical men, 
that some immigrants entering the town were visibly ill and had the aspect of low fever. 
b. From a trustworthy official source (non-medical) intimately acquainted with the town 
of Bombay, I have the written statement that there were seen, in 1877, a considerable 
number of immigrants who were suffering from fever and prostration on their arrival in 
the town ; the men and young children suffered most (a noteworthy remark, since here, as 
in Europe, mothers of families seemed to get famine-fever first, and then to communicate 
it to their associates : H. V. C.) Again, it is reported that at a station near Bombay where 
immigrants were stopped in August 1877, ' some of the children and a few of the men had 
fever,' this statement coming from a medical authority disallowing the existence of famine- 
fever at the time. Again, in those quarters of the town where the fever was worst, ' cases 
like this occurred, a party of seven or eight immigrants arrived with, say, three of 
them having fever ; in a day or two, there would probably be five or six of the same 
party attacked with the disease ; there is no doubt at all of such cases having occurred.' 



12 SPIRILLUM FEVER. 

Proof under c. — Sholapore town and district suffered severely from 
famine and fever in 1877, and again in 1878. In May of this last year 
Dr. A. (who had taken part in the enquiries at Bombay) visited, at 
my request, the above-named town and neighbourhood ; he promptly 
reported in detail eleven cases of fever, unselected, finding the blood- 
spirillum in eight. In consequence of this information I went to Shola- 
pore after a few days, but was too late to confirm the observations ; and 
not being able to remain away from the Presidency, had to return with- 
out fresh proof However, upon examining the specimens of dried and 
stained blood which Dr. A. had himself prepared, I found the parasite 
still visible unequivocally in one, and probably in two other slides, which, 
like the majority, were too imperfectly prepared (from inevitable diffi- 
culties met with) to allow of thorough scrutiny. Of the cases, ten were 
Hindoos ; five were males, eight were town residents (one in respectable 
position), five being wandering mendicants ; three were seen in villages 
near ; several of the poorest gave a history of famine suffering ; all had 
symptoms more or less characteristic of relapsing fever, some describing 
the relapse, and this was so with the destitute woman J. S., whose blood 
furnished the decisive evidence ; she was admitted a second time with 
fever (entered as being ' ague ') into the Municipal Dispensary, and died 
there of dysentery (' bowel complaint '). Contagion in the family was in- 
dicated once ; none of the patients had travelled to Bombay, and all 
denied having been in contact with travellers from a distance. I found- 
the country parched up, and villages desolated, but saw few cases of 
fever ; this is no matter of surprise, however, considering that the 
specific pyrexia is never continuous, and may be very brief In practice, 
evidence from the blood is equally contingent, and a thorough investi- 
gation of relapsing fever may require a longer time and more watching 
than cases of ordinary malarious fever ; not to insist upon special know- 
ledge, skill, and patience with the microscope. How readily the truth 
regarding the nature of the late fever sickness in the Mofussil might have 
been elicited on the spot, was shown by the result of the brief visit above 
described. 



SUMMARY OF THIS CHAPTER. 

The late excessive fever sickness undoubtedly followed upon dearth; 
the circumstances of its origin and early course indicate its non-malarious 
character ; upon analogical grounds it might have been true famine- 
fever; and the presence in the Mofussil of relapsing or famine-fever 
{i.e. of pyrexia with spirillar blood contamination) was demonstrated in 
some cases. This combined testimony points to but one inference, 

c. What kind of fever the above might be, is not obscurely indicated by the following in- 
stance belonging to the series of documents bearing on 'Contagion' which are quoted 
hereafter. Ii is that headed 'The Bala Family,' and contains a statement that the mother 
coming with the family from Satara, arrived at Poona, and fifteen days after her arrival 
there she became laid up with fever and remained ill for about a fortnight ; when her eldest 
son, hearing of her illness, went from Bombay, and removed her from Poona, whilst in a 
di;lirious state, by the G. I. P. Railway to Byculla station. A few days after her arrival 
in Bombay, her husband became ili, and then all the five children, in succession, with spi- 
rillum fever ; some of them died in hospital. In offering these remarks, I do not wish it 
to be supposed tliat all the febrile sickness seen amongst immigrants was of this specitic 
kind ; for probably no epidemic has had a wholly exclusive character. 



EPIDEMIC IN DISTRICTS. 13 

which is not contradicted by other facts, and which legitimately explains 
all the chief phenomena of the epidemic. 

The main valid objection to this conclusion, is the circumstance that 
famine-fever was not detected in the Deccan by resident observers ; and 
a suitable reply to this would be the fact that at the height of public 
sickness in Bombay, and under the most favourable conditions for 
enquiry, the prevalence of the new disease was both ignored and authori- 
tatively denied. 



14 SPIRILLUM FEVEI 



CHAPTER II. 

HISTORY OF THE FEVER EPIDEMIC IN BOMBAY. 

Normal Data of the City. — Situation, N. latitude, i8"57' ; E. longi- 
tude, 72°5i' ; site upon one of several low, level islands at the mouth 
of an estuary ; population, near 700,000 ; subsoil, igneous rock (trap 
or basalt), clay shale, calcareous sand, and marine alluvium. 

The compact native town (here alone concerned) is mostly built 
upon a central, flat, alluvial area, often little higher than spring-tide 
level ; a part constructed upon the eastern raised and rocky foreshore 
(elevation 100-200 feet) did not escape the disease ; whilst the similar 
western coast line, also of trappean hills, where Europeans and the 
wealthier natives reside, was practically unaffected. The streets are 
mostly narrow and tortuous, the houses high and constantly overcrowded; 
mean density of population 6 to 12 square yards per individual in 
central parts. Dramage of rain-water and liquid sewage as yet defec- 
tive ; street cleaning is attended to, house scavenging is chiefly manual. 
The food and water supply are good; drinking wells are now little 
resorted to. 

The population is mostly Hindoo, about one-fourth being Ma- 
homedan, one-twelfth Parsee, and a smaller proportion of other non- 
indigenous races ; the several sections do not eat together or intermarry, 
and, on the other hand, particular subsections are closely aggregated. 
The humbler classes (alone in question here) consist of day labourers, 
mill hands, handieraftsmen, servants, petty traders, and mendicants who 
freely wander. There is no system of poor relief, and the destitute 
paupers suffer much. In general wages are sufficient, and it could not 
be said that want is commoner here than in the cities of Europe. Of 
the sexes, male adults predominate ; especially during the open season 
(October to May), when labourers from the interior annually resort 
for labour to Bombay, returning to their homes and fields before rain 
arrives. 

The climate is tropical; mean annual temperature, 80° F., with 
daily range, 8° ; absolute range, 23°; mean annual dew-point, 72° ; hu- 
midity, 75 (saturation being i), with a range of only "19 ; mean baro- 
metric pressure, 29'8i5 ; daily range, ■103 ; the sea-breeze blows 
18 hours of the day ; the rainfall averages over 70 inches per annum, 
and attends the S. W. monsoon from June to October. 

Normal Mortality of the Town. — An elaborate mortuary registra- 
tion has been in use for some years ; of late nearly 20,000 deaths occur 



EPIDEMIC IN BOMBAY. 1 5 

annually from all causes, amounting to a rate of nearly 30 per mille. 
A chief and uniform heading is ' fever ' (remittent), under which are 
reckoned more than one-fourth of all casualties at all ages ; it is a cha- 
racteristic of the Bombay returns. Cholera, small-pox, measles, are 
items fluctuating, but never absent ; phthisis pulmonalis, 3,000 deaths; 
other lung inflammations, 2,000 ; from dysentery and diarrhoea, 2,000 ; 
infantile convulsions add to the large mortality of early years, so signifi- 
cant in this town. Most recognised diseases of Europe are found in the 
mortuary lists, but some are unknown (as scarlet fever), some not very 
long familiar (enteric fever and diphtheria), and some await recognition 
(typhus, simple and recurrent). 

Abnormal Events. — In the absence of local drought or dearth, or 
of other unfavourable change in the outward state of the town, there yet. 
occurred in 1877 and subsequent years, a sanitary calamity which will 
not soon be forgotten. This consisted of an enormous influx of famine- 
stricken peasantry, and the concurrent increase of fever mortality shown 
in Chart No. i. Column C. 

Though the Presidency town is distant 300 or 400 miles from the 
foci of want in the Deccan, yet free communication was maintained by 
rail, road, and indirectly by sea ; there being, too, ready transit by rail 
from Central and North-West India, where also famine prevailed. As 
a centre of textile manufacture and remunerative labour, it early became 
a refuge of the remote needy populations, and the extent of immigration 
was enormous. Thus, in June 1877 (when the fever-deaths were most 
numerous) it was estimated that the population had increased to 
1,000,000, or by 30 to 40 per cent, beyond the normal ; and to a miti- 
gated degree the influx still continued, there being counted in the main 
roads from the chief area of distress during the last fifteen days of 
August, 18,884 paupers, in various stages of destitution. I am unable to 
offer any estimate of subsequent years, or of the numbers coming from 
Central India, and further northward or westward from Kattiawar ; but 
the total was doubtless many thousands of persons, who had no intention 
of immediately returning to their desolate homes. Contrary to custom, 
whole families migrated to the town, with a corresponding effect upon 
the statistics of sickness. The new comers needing food and seeking 
work, wages and the prices of grain were affected, and doubtless the 
quality of food sold was sometimes bad. Untrained labour was available 
chieflv in the new docks and on coal ships, and the influence of arduous 
exertion upon the exhausted frame of men and women may be readily 
surmised ; skilled labour was limited to the spinning and weaving mills, 
and to the many private looms for cotton and silk fabrics, in even more 
crowded buildings. The depressed mental aspect of these strangers was 
often too obvious to be overlooked. 

To my mind, however, there remains the most important con- 
sideration of all, affecting both severity and propagation of the pre- 
valent disease ; for house accommodation, never superfluous, had not 
materially increased in 1877, and the lodgment of so many immi- 
grants necessarily led to excessive overcrowding, with its inevitable con- 
sequences. In most houses the subdivision of rooms was extreme, 
passages and light being reduced to a minimum ; cleanliness was 



1 6 SPIRILLUM FEVER. 

impracticable, and the removal of excreta interfered with ; workshops, 
and the lanes, temples, verandahs, and markets became sleeping places, 
and a distinct proportion of the sick were quite homeless. 

I have not insisted upon the elevation and character of the soil in 
the chief fever localities of Bombay, from not detecting any uniform 
relationships of these conditions with prevalent sickness. Nor from the 
large additions to the population in 1877-78, could the true death-rate 
of the town be elicited. 

Course of Sickness^ 1876. — Concurrent with imminent distress in 
the Deccan, an unusually large migration to Bombay began in the 
autumn; yet the fever mortality did not immediately xvs>t(Tjide the Chart). 
From hospital data I know that even early this year destitute individuals 
had arrived in the town from Northern India (where also scarcity pre- 
vailed), and that famine-fever had appeared. 

1877. — This was the year of greatest suffering both in Mofussil and 
at Presidency, In Bombay, it could not be said that mere insanitation 
was so much worse as to account for the augmented death-rate ; nor 
was the local meteorology at fault; e.g. annual means — barometric pres- 
sure, 29-846 ; temperature, 8i°'2 ; dew-point, 72°7 ; humidity, 75, and 
rainfall 69 "89 inches at Colabah. The mean temperature of May, with 
so much fever sickness, was 85° '5 ; dew-point, 75° "8 ; no rain fell from 
March until June, and not an inch during the previous five months — 
these data being adverse to the hypothesis of malaria as the cause of 
fever. More important, therefore, seems the conjunction, at this period, 
of maximum immigration with maximum sickness and mortality. The 
fever-deaths starting in January with a slight excess over 1876 (though 
not over earlier years), viz. as 686 to 489, in March had risen to more 
than double (1,265 to 527), and in April, May, and June they were 
treble as many, the greatest number being reached in May, viz. 1,617, 
as contrasted with 511 in the previous year. 

With the rise of mortality in March, and the prospect of further aug- 
mentation through the crowds of famine-stricken then daily flocking to 
the Presidency, public attention became imperative ; and a Relief Camp 
capable of lodging 2,000 persons was erected on the outskirts of the 
town, whither were conveyed by the police such destitute or sick persons 
as they could best induce to move. It was here that the nature of the 
prevalent fever was surmised and demonstrated ; ' and as this assemblage 
may be supposed to represent the population of the worst lanes and 
houses of the town, I may add that a few days after its formation, of 
■659 inmates 309 were found to be ill or ailing, others were much re- 
duced, and some unaffected were in attendance on families or friends ; 
about one-half the whole were recent immigrants, the rest being residents 
of over six months' standing. The authorities soon after took measures 
to check further influx of the destitute, and the monsoon season being 
at hand, many immigrants returned to their villages ; by July, therefore, 
the mortality had declined to 976, but rain again failing, there was a 
temporary arrest of the exodus and fresh influx, the fever deaths rising 

I To Mr. Thomas Blaney, an esteemed medical practitioner in benevolent attendance 
on the sick, and a respected town councillor, belongs the credit of independently recog- 
nising this disease and engaging actively in its mitigation. 



EPIDEMIC IN BOMBAY. 1 7 

to 1, 006 in August ] thenceforward, however, prospects brightening 
somewhat in the Deccan, the stress in Bombay and the mortality de- 
clined to December. 

Other details are the following : — The proportion of residents and 
strangers who died during 1877, is clearly indicative of the extraneous 
mass of mortahty intruded through immigration ; thus, whilst in 1876 
strangers contributed less than one-half the total deaths, in 1877 their 
casualties w^ere as 20,000 to 12,000 of residents ; and it is said upwards 
of 6,000 strangers died in Bombay during the dates April to June, when 
'fever 'was at its height. Of the total number of deaths in 1877 as 
compared with 1876, no less than eleven-twelfths were contributed by 
new-comers arriving within the famine period. 

It was clearly shown that the excess of fever-deaths occurred almost 
solely, in those quarters of the native town where the famine-immigrants 
lodged ; and this quite irrespectively of local malarious proclivities, as 
displayed in previous annual returns. 

It was also proved that the high fever mortality prevailed chiefly, 
amongst the classes of people forming the mass of immigrants, and the 
worst lodged ; these w^ere Hindoos in 1877. Thus, amongst Hindoos (of 
the Maratta race mostly) the normal fever death-rate being ten per mille 
and tolerably uniform, in January 1877 the estimate rose to 15 "50, and 
in succeeding months to 18 "41, 26 -89, and 40-34 per mille ; amongst 
Hindoo outcastes the normal rate of 6 "63 per mille similarly increased 
to i8"24, 28*30, 33'i7, and in May to 4478 per mille. On the other 
hand, amongst the Mussulmans the contemporary rise was from normal 
10 '20 per mille to only 21 "91 ; amongst Parsis from 3-53 per mille to 
1 1 79 ; and amongst Europeans the monthly death-rate from fever con- 
tinued to be regulated by one, two, or no deaths. Such race differences 
are unprecedented in normal years, and their connection with corre- 
sponding proportions of newcomers seems undoubted ; for not only were 
they most marked when immigration had reached its height, but in detail 
they are equivalent to the components of superadded population ; the 
great majority of strangers being Hindoos and outcastes from the Dec- 
can, yet not a few Mussulmans chiefly from Northern India, and the rest 
from Persia and adjoining countries. 

A further notable feature of the year was the increased mortality 
amongst women and children, in accordance with the larger number of 
families who this year accompanied the male bread-winner in his search 
for work, being driven by want from their home. Infants from seven to 
twelve months died from ' fever ' at the estimated rate of 300 per mille, 
adults from twenty to thirty years at the rate of 11 "81 males and i6'57 
females ; these proportions also being quite exceptional. An important 
datum which cannot be elicited from the mortuary Returns, concerns the 
amount of illness short of death, which w^as due to fever ; or, in other 
words, the mortality rate of that disease. As indicated by brief experi- 
ence at the Relief-camp, this rate was about 9 per cent. ; which, assuming 
that 5,000 of the 7,000 excessive fever-deaths in Bombay were due to 
famine-fever, would give a total of more than 500,000 cases of illness in 
1877 from this one cause. The total death-rate of the town, as esti- 
mated on the census of 1872, amounted to 52-0 per mille, as contrasted 
with 32-25 per mille in the previous year of 1876 ; the actual ni^mber 

c 



1 8' SPIRILLUM FEVER. 

of casualties registered was 33,511, and of these 12,832 were due to 
' fever,' no other heading being nearly so predominant. 

In connection with famine-diarrhoea, which was shown to be so pre- 
valent in the Presidency town of Madras (holding not unlike relations 
to its own country districts), I would add that the municipal report 
indicates a similar affection may have prevailed here, especially amongst 
destitute immigrants ; the absolute number of deaths from cholera (so 
interpreted) and diarrhoea m excess of the normal mean was, however, 
inconsiderable as compared with the augmented fever-deaths. 

1878. — Though famine immigration from the Deccan greatly di- 
minished, yet the fever mortality did not subside in proportion ; and 
from hospital data, I am able to state that now the resident poor of the 
town suffered more than in the previous year. The total deaths exceeded 
those of 1876, the latest normal year, by 6,116 ; and of this surplus 
4,007, or two-thirds, were due to 'fever ;' vide the Chart. As in 1877, 
but rarely in normal years, the fever mortality augmented in May and 
declined in June, when it is the custom of country labourers to return 
to their homes ; in general features too, of caste, sex and locality, the ex- 
perience of the great famine year was partly repeated. The fever sickness 
here seemed to be kept up by localised epidemics, the chief of which, 
according to my hospital data, occurred among weavers and other Mus- 
sulmans ; and on testing these data of ' relapsing fever ' with those of 
fatal ' remittents ' shown in the Municipal Returns, I find the clinical 
experience may have been (as was not unlikely) a sample of larger facts; 
thus, during 1878 fever-deaths in the town amongst Mussulmans, so far 
from declining distinctly, as did those amongst Hindoos, are found to 
be rather in excess of the previous years, viz. as 2,477 to 2,422 ; and 
375 weavers in the town died, against 186 in the previous year. A 
second sub-epidemic outbreak was detected amongst low-caste immi- 
grants from Kattiawar, whose numbers brought to hospital aided in the 
May predominance of spirillum fever shown in the Chart, Column E. 

1879. — Fever mortality but slowly declined, the deaths being 8,445, 
or more than 50 per cent, in excess of the previous normal mean ; its 
monthly distribution is shown in the Chart. Experience at the G. T. 
Hospital showed best the frequency of relapsing fever when carefully 
sought for, there being four or five times as many admissions there as in 
the larger Native hospital (alone referred to in the Chart) ; and I had the 
clearest evidence of its spread by contagion. Deaths amongst Mussul- 
mans still predominated in the town ; and equally in my wards, cases of 
relapsing fever amongst them. There occurred this year another minor 
famine immigration of ryots from Kattiawar, and several cases of specific 
fever from this group were admitted into the G. T. Hospital ; two died 
(father and daughter), and I note that here ' remittent ' fever deaths were 
registered outside. By caste these people were Jains, and the municipal 
returns show an augmentation of fever mortality in this sect ; the signifi- 
cance of the datum, like that of contemporary high Brahmin mortality, 
being not obscure to medical practitioners acquainted with the local 
history and contagious properties of the new disease. 

1880 and 1881. — Traces of the late epidemic still remain, notwith- 
standing subsidence of the main cause giving origin to it in 1876-77 ; 



EPIDEMIC IN BOMBAY. 1 9 

and in this respect, as in so many others, experience at Bombay has 
resembled that of some large cities of Europe. 



Memorandum on the contemporary state of Province.s in 
DIRECT communication WITH BoMBAY. — In nearest and fullest associa- 
tion were the famine districts of the Deccan, whose state I have already 
described and whose connection with the local epidemic was immediate 
and indisputable. Also within Presidency limits is the Kattiawar penin- 
sula of Gujerat, where prevailed famine and fever sickness, almost as 
early and as marked as in the Deccan itself ; and whence, too, was much 
immigration at similar and later dates to the Presidency. Due promi- 
nence being accorded to these instances, I would next allude to more 
distant countries. 

As a wealthy commercial town uninvolved in the prevalent distress, 
Bombay became more than ever the centre towards which the needy 
turned when compelled to leave their homes ; and with railways com- 
monly accessible, distant parts freely furnished their quota to the sick 
in the town. As regards Madras, where famine in 1877 was so severe, 
there is not much evidence of migration hither, Vv'hilst from Central 
India, Oude, Rajputana, and the North-West Provinces there is much 
concurrent testimony of large migrations to Bombay, in consequence of 
scarcity, from 1876 onwards ; and it is notorious that with and after the 
dearth in those parts, there ensued a fever mortality of appalling extent. 
Regarding the nature of that fever I have sought in vain for adequate 
information ; it seems Europeans were not spared. From many towns 
in the above-named provinces (a long list is before me, and Azimgurh 
perhaps oftenest entered) immigrant Mussulmans (weavers chiefly) and ■ 
Hindoos (ryots and low-caste) early began to flock southward, the 
journey by rail from Allahabad not occupying more than four or five 
days ; some walked long distances. On arrival they lodged in parts of 
the native tovv-n less crowded by the Marattas, but as soon (1876) and 
afterwards as often as these (1878) became inmates of the fever wards 
of the hospitals in Bombay. I am unable to say (the people being un- 
usually timid and prevaricating) if these immigrants brought fever with 
them into the town ; but many displayed the specific infection in typical 
form, and that very soon after their arrival. Their resident fellow-caste 
men were contemporaneously affected ; and, in sum, the evidence regard- 
ing the distant famine area of Northern India is similar to that of the 
Deccan itself. See p. 27. 

That in Persia and China dearth and disease were almost contem- 
porary with the events in Western India is well known, and fever persisted 
after the famine. Its true character is unknown to me, for the few cases 
admitted into the G. T. Hospital of pilgrims and others coming in 
native craft from the Persian Gulf, Jeddah, and Aden, were not at a stage 
or in a condition to furnish decisive evidence. This might be looked 
for, even had the fever been specific. According to my late experience, 
future accounts of fever eyjidemics in the East may be radically defective, 
if they do not include adequate information as to the state of the blood 
during pyrexia. This remark is capable of general application. 



20 SPIRILLUM FEVER. 

Interpretation of Events at Bombay. — In the Municipal mortuary- 
returns the term ' fever ' is held to signify mainly malarious ' remittents,' 
with or without local complications ; a very small proportion, viz. not 
more than one-twelfth part, of the mortality under this heading being 
attributed to ague, simple continued fever, and enteric. 

Normal years (Chart i, Col. C, 1875-76). — During the decennium 
prior to 1877 the fever-deaths were distributed throughout the year 
almost uniformly, there being rather the fewest in the third quarter, i.e. 
237 per cent, and rather the most in the first quarter, i.e. 26 per cent. 
Such a disposal does not favour the view of their being due solely to 
malarious influence ; nor does the fact of there being rather more 'fever' 
deaths in April and May (hot season) than in October and November, 
or immediately after the heavy rains, when miasm proper might be ex- 
pected to abound. While it is allowed that in this island conditions of 
malaria-production should be present for a considerable portion of the 
year, yet they cannot be supposed to obtain in the crowded native town, 
where the foul state of the surface soil, including the foreshores, and the 
habitual overcrowding preferably claim attention. The actual additions 
to population here from October to May, due to immigration of healthy 
male labourers, have not been precisely estimated ; but it is probable 
that they aid in the maximum fever mortality of December and January 
(cold months), which amounts to 17 per cent, beyond the monthly mean, 
and apparently is not due wholly to local complications. There is, 
however, a distinct tendency in ordinary years to increase of the fever- 
deaths during the hot month of May ; and both the epidemics of 1864- 
66 and 1877-78 reached their acme in this month. With the rains in 
June, the fever mortality has always promptly declined. From these and 
other hospital data, I infer that the ' remittents ' of Bombay are not purely 
malarious ; and they may include modified forms of ' continued ' fevers 
{i.e. typhus and enteric), due to causes similar to those recognised in 
European cities. 

Abnormal years (Col. C, 1877-8-9). — No change of name being 
made in the fever registration of 1877, the immense augmentation of 
deaths at that crisis is recorded under the head of ' remittent ' fever, yet a 
reference to my Chart should, I think, at once dispel the idea of such 
augmentation being due to malaria ; and if in ordinary years this 
eminently seasonal influence does not seem of primary importance at 
Bombay, during the late augmented sickness it must have become 
greatly modified to permit of its application as the immediate and 
adequate cause of mortality. No such modification, however, was shown 
to occur, nor could the adoption of the name 'remittent fever with 
spirillum ' stand in place of demonstration ; such a nomenclature serving 
only to increase a confusion already embarrassing enough. It was not 
supposed that malarious influence abounded more than usual during 
1877-78 ; and had this been the case, there would remain the difficulty 
of accounting for the epidemic spread of the new fever. In sum, I find 
no valid evidence in favour of the view that the late excessive fever 
mortality was due solely to malarious influence. 

No addition to precise knowledge accrues from attributing the sickness 
simply to intensified mal-hygienic conditions, for filth, overcrowding, and 
hardship of fife operate only by favouring the extension of specific disease. 



EPIDEMIC IN BOMBAY. 21 

Lastly, as regards other general agencies ; on consideration, I per- 
ceive no essential connection of the late disease with local climatic 
changes of temperature, moisture and wind, or with geodic relations of 
soil, elevation and ground-water. 

Analogical Inference. — On comparing the late experience in Bombay 
with that of European cities under similar conditions, it became in the 
highest degree probable that a form of contagious typhus would arise, 
the presence of which would serve adequately to explain all the pheno- 
mena ; and that a virulent type of relapsing fever did, in fact, make its 
appearance the following data will show. 

Direct Evidence. — This came from two sources, — chiefly from the 
hospitals, where sick emigrants and residents were examined, with 
positive results afterwards stated ; but earliest from the Relief Camp 
mentioned above. 

Here, as member of a visiting committee, I attended for three weeks, 
on April 8, 1877, seeing the following instance : — 

Case V. — G. D., adult male, robust, porter at a railway-station where many 
famine-immigrants from the Deccan left the trains daily arriving; admitted with 
his family April 3, being ill with fever, and two others had been attacked before. 
His axillary temperature was io5°-5, rising to 106^ "2 next morning ; on the seventh 
evening it was 104°, and then 1 found the blood to be full of active spirilla ; there 
was a marked crisis the same night, the temperature next day sinking to 95° "4, and 
the blood-parasite being no longer visible. The man remained free from fever for 
seven days, and then (fourteenth day of illness) underwent a relapse (spirilla again 
found), which lasted six days, ending abruptly with a fall in temperature of 9° ; he 
became extremely ill during the febrile stages, having typhus symptoms with delirium; 
and was much reduced afterwards. Two of his young children acquired the same 
fever while in camp. 

Amongst other instances in which the blood was scrutinised, was 
that of a pregnant woman who aborted at the crisis of her first attack ; 
here the blood-parasite had been detected previously, and as it was 
found in three other fever cases, the demonstration appeared sufficient ; 
seeing that the general symptoms in all were so usually alike, and that 
when the state of the blood gave negative testimony, an adequate ex- • 
planation was always forthcoming. 

The committee had notes taken, with charts, of 48 unselected sick 
persons: males 31, females 17 ; more than half under 20 years of age, 
youngest i^ year, the oldest 70 years ; 10 were residents, 35 immigrants, 
and 3 of unknown home. The general symptoms, personal history and 
social condition were generally characteristic of relapsing fever, and 
sometimes typical ; the chief forms of this disease also were here 
illustrated, and I now perceive that the enquiry really concerned a kind 
of epitome of the town fever. At first 25 per cent, of the cases were 
recognised as being certainly, or probably, examples of spirillum fever : 
afterwards, on reperusing the original notes with fuller practical know- 
ledge of the disease, I concluded that nearer 75 per cent, may have 
been such. Contagion was strongly indicated from the first ; thus, the 
number of sick increased in camp : two out of five hospital assistants were 
attacked with severe fever, and one died with typhus symptoms ; a cook 
and another person were seized with similar fever, and 14 of the patients 
examined were well before coming hither, being affected at periods of 
«ix days and upwards after their arrival ; some of the new attacks occurred 



22 SPIRILLUM FEVER. 

in the temporary hospital itself — members of a family living together were 
thus implicated, and in two such instances noted the children showed 
the blood- spirillum. The mortality in camp was less than obtained in 
the J. J. Hospital at this time, because the cases were often milder, and 
such as the friends would have kept at home ; but two houseless and 
friendless relicts of the camp, on its dispersal before the rains, died in 
the above hospital with demonstrated spirillar infection. According to 
this summary, it may be affirmed that much, at least, of the excessive 
fever sickness in Bombay, at the height of the epidemic, was due to 
relapsing fever ; and it would be difficult to conceive of better testimony 
than the above, of a practical kind. 

Hospital Statistics. — The value of these data rests on the admitted 
fact that sickness in the town and under treatment, was alike as regards 
subjects affected, locality, degree, date, and character. The total 
medical and surgical accommodation in the two Bombay hospitals 
amounting to one bed per i,ooo inhabitants, it could not be expected that 
the medical wards would afford more than a dim reflex of the sickness 
outside ; yet that the image was a true one I entertain no doubt what- 
ever, from both local knowledge and direct comparison of disease in 
members of one family, part of whom remained at home and part came 
under treatment. See also below. 

J. J Hospital (Chart i. Col. D).' — In normal years the seasonal 
increase of remittent fever is clearly indicated ; thus, in the five years 
previous to 1876, the mean monthly admissions were the highest just 
after the rains, viz. 30 8 in November, and least at end of hot season 
or beginning of monsoon, viz. in May 9. No notable departure from 
these means occurred until 1876, or the year immediately preceding the 
epidemic, when from March onwards there was a decided and continu- 
ous increase of admissions, as follows : — February, mean of the five 
previous years, 17 '6, actual in 1876 the same ; but afterwards an excess 
by months in order of 7, 6, 7, 10, 12, 11, 10, 12, 8, 9. The deaths from 
remittent fever were 30 per cent, of admissions in 1876, against the 
mean of 31 "3 per cent, a difference which shows that febrile affections, 
if commoner, were not more severe than previously. These numbers 
could not be displayed in the Chart, and they are here mentioned 
because ' relapsing ' or ' famine ' fever, if not first beginning about March 
1876, yet was first noticed at this date (see below) ; and the rise in 
hospital admissions may have corresponded to the initiation of the new 
fever. The town mortality, obviously, might not furnish so early indica- 
tion of an incipient disease, less fatal than usual. 

Abnormal Years. — The very first monthly admissions of 1877 were 
more than two-and-a-half times the mean, which is a more abrupt 
augmentation than elsewhere shown in the Chart. In March there 

I These statistics are given on my sole authority, official returns not including relapsing 
fever ; though numbers are small, yet they have a proportionate as well as direct value ; 
limitation here being due to frequent overcrowding of the medical wards, which necessi- 
tated the rejection of fresh fever patients. During 1877 no fewer than 2,947 sick were re- 
fused admission, mostly suffering from fever. 

Data from the smaller G. T. Hospital could not be shown in the Chart ; so far as I am 
responsible, they correspond with the above : fifty cases of demonstrated spirillum fever 
being admitted in parts of April and May, and during parts of November and December 
twenty r7iore ; oVjservation was then stopped on account of my contracting the fever, and 
temporarily leaving India. 



EPIDEMIC IN BOMBAY. 23 

occurred a further rise, which may be traced also in Cols. C and B ; 
and in May a greater advance to near the maximum (see the Col. E of 
this date), which corresponds to the actual maximum of fever-deaths in 
the town (Col. C) ; in and after July till October, hosj)ital admissions 
remained steadily high, the medical wards being constantly full. I was 
absent from this hospital for the next five months ; the hospital admis- 
sions were fev^^er (see Cols. D and E) ; on resuming charge in April, 1878, 
there was a fresh exacerbation of so-called remittent fever, lasting till 
May (see also town deaths, Col. C), and then a decline took place to the 
end of the year, when I again left. Col. E very closely repeats these 
febrile movements : they are less evident in the town registers, which 
deal with fatal events only. In 1879, (he J. J. Hospital entries ap- 
proached the normal, yet with this quasi-normal state relapsing fever 
was present ; which is a point worthy of notice, as indicating how at the 
same institution the end of an epidemic comes to resemble the begin- 
ning. That the fever had not ceased was, however, fully proved by 
observation at the G. T. Hospital ; instances still occurring at the time 
of my second departure from India, early in 1880. 

Analysis of the above Data. — Little is known of any period before 
April 1877 ; 1 from the following month of May until that of December 
1878, no fewer than 1,468 cases of 'remittent ' fever were admitted, or 
about four times the mean of the preceding years 1875-76. Of these 
1,249 were specially noted : 910 had the blood examined, and in 509 
(near 56 per cent.) the spirillum was seen ; in the remaining 401 it was 
not found ; there were 339 cases less acute or obviously compHcated, 
which were not submitted to minute scrutiny ; total 740 cases, in which 
the blood-parasite was either not seen or not looked for. But these 
negative instances were admitted under conditions of date, race, home, 
lodging in the town, family, occupation, sex, age, and reputed illness, 
identical with those of the positive series ; and not seldom the history 
and symptoms of their fever were, also, highly presumptive of specific 
infection. In my judgment, therefore, it seemed likely that, altogether, 
at least three-fourths of the 1,468 admissions belonged to the famine- 
fever series; i.e. a sum of 1,243, which is not far short of the actual 
excess (1,284) of admissions beyond the mean of two previous years ; 
and hence the inference that, in reality, ordinary remittents were not 
much increased at the height of the epidemic. As this remark will 
apply to sickness in the town, I should add that my opinion has been 
formed deliberately, and upon many grounds indicated in the following 
chapters of this work. 

In detail, comparing these clinical data with the mortuary returns 
of the town, I note that the hospital gave earliest, fullest, and most 
continuous indication of the serious state of public health. Oscillations 
of the epidemic wave were necessarily less well indicated, yet the rise 
in May 1878 was concurrent. Caste. — Spirillum fever was much the 
commonest amongst Hindoos in 1877, and so fever in the town ; in 
1878 it was more frequent amongst Mussulmans, and so fever-deaths 
in the town. Residence. — There is a remarkable coincidence between 

1 My appreciated predecessor in office, Dr. Henry Cook, informed me that, upon re- 
trospection, he had found more than one instance of relapsing fever dating back to the 
autumn of 1876 ; and experience at the G. T. Hospital was equally explicit. See below. 



24 SPIRILLUM FEVER. 

localities showing most fever-deaths and those furnishing most admis- 
sions for relapsing fever : e.g. Dongri was crowded with famine-immigrants 
from the Deccan, numbers of whom showed sickness and were removed 
tj the hospital near, and many more died at their residence ; from 
personal visitation of the houses I know that the two classes of cases 
were identical, the sole disease being true famine-fever. For Mahom- 
medans, there was the instance of Nagpada (Kamatipura) in 1878, where 
also I inspected houses of my patients, and found in them relatives and 
others unwilling to go to hospital (they had a dread of autopsies), who 
were sick with the same specific fever, as proved by the examination of 
blood-specimens taken on the spot. According to the municipal returns 
the fever-deaths in Kamatipura were as numerous in 1878 as in 1877, 
which was not so in other crowded quarters ; and the clinical data here 
furnished a rational and adequate explanation of this exception. Occu- 
pation. — ' Labourers ' was the common term for relapsing-fever admis- 
sions and for town fever-deaths, in unusual proportion ; the great variety 
of professions named by my patients showed further how widely the new 
fever had spread ; e.g. noting in 1878 several instances of itinerant 
vendors of tea and sherbet, I found also in the municipal death-returns 
that fever, outside hospital, had been unusually fatal in this small com- 
munity. Age and Sex. — Under these headings fever-deaths in the town 
were somewhat unusually distributed, and an accordance herewith was 
clearly noted in the hospital statistics of relapsing fever, which showed 
here, as in Europe, a predominance affected of male adults. General 
Condition. — The results of defective nutrition were frequently most 
apparent, especially in wandering immigrants and beggars ; yet in 
hospital a larger proportion of better-conditioned residents were admitted 
than was indicated in the town deaths : this difference being due to 
residents naturally seeking their accustomed aid, whilst strangers were 
ignorant and more prejudiced. Since generally the worst or abandoned 
cases of illness were brought to hospital by friends or the police, the 
death-rate of the fever might be expected to rise beyond that in 
European cities ; and such was the case, it being 19 "5 per cent, of 
treated, as contrasted with 5 or 10 per cent. ; here, again, was no real 
anomaly, but rather an indirect confirmation.^ 

The above memoranda are offered for the information of those who 
had not the advantage of being on the spot, for it was never supposed 
by medical officers at Bombay that the hospital admissions for ' fever ' 
were different from cases of ' fever,' generally, in the native town ) and 
I conclude that the inference of identity of nature, which follows from 
all ascertained likenesses of the two groups (their comparative severity 
alone excepted), is as valid as it is natural. As samples only of the 
larger town statistics, hospital data might not quite tally in numerical 
proportions ; but as regards character and distribution of the fever, they 
would be and are a good and sufficient test. 

' From a return I had made, it was found the mean ntmiber of all cases brought to 
hospital in a moribund state in 1875-76 was 297 yearly ; in 1877-78 the annual mean was 
612, and the monthly maxima corresponded to dates of most admissions for ascertained 
relapsing fever. In normal years the death-rate of remittents at the hospital was (mean 
of five latest) 31 '3 per cent. ; in 1877 the deaths were 292 in 1,073 admissions, or, in spite of 
the terrible distress then prevail ng, only 27*2 pi r cent. ; in 1878 the rate was 28 7 per cent., 
and in 1879 it ruse to 36 6 per cent. ; compare these years in Col. D of the Chart. 



EPIDEMIC IN BOMBAY. 2$ 

The special value of hospital experience is further illustrated by the 
following analysis of 48 7 cases of demonstrated spirillum fever. 

1877. — Hindoo Marattas were mostly affected, there being 206, with 
34 deaths ; whilst of Mussulmans of varied origin there were only 
50 admissions, with 6 deaths. The Hindoos came from the Deccan 
famine districts (even the more distant), with a contingent from the 
Concan, doubtfully indigenous ; herein is strict accordance with the 
town fever mortality. 

1878. — These proportions were now reversed, for of 235 admis- 
sions, chiefly in April and May, only 54 (with 7 deaths) were Hindoos, 
mainly from Kattiawar; whilst 173 (with deaths 30) were Mahommedans, 
mostly from Northern India ; here, too, is close accord. And, to con- 
clude, all the particulars collected prove clearly the late epidemic in 
Bombay was of composite character, being connected with dearth in 
several countries through famine immigrations, which kept up the supply 
of susceptible material, in addition to that afforded by the resident 
pauper population. Hence, also, the sustained character shown in 
Column C of Chart i. 

As to type of fever, the Hindoo agriculturists in May 1877 showed 
the most acute or sthenic form ; and the Mussulman weavers in 1878 a 
less pronounced, typhus-like and asthenic type. 



SUMMARY OF THIS CHAPTER. 

The late excessive fever sickness in the town was independent of 
local dearth ; the circumstances of its first appearance and early course 
indicate its non-malarious character ; upon analogical grounds it was 
likely to be true famine-fever ; and, in fact, specific pyrexia characterised 
by the presence of the blood-spirillum, was detected in a large number 
of instances. This combined testimony points to but one conclusion, 
which is not contradicted by other facts, and which legitimately explains 
all the chief phenomena of the epidemic. 



APPENDIX TO THIS SECTION. 

Origin of the late Epidemic. — The little that is known may be use- 
fully recorded, both for future guidance and as evidence that sickness 
began gradually and spread contingently, at Bombay as in European cities. 

The earlier hospital records were seldom complete enough for use here, 
and even fuller data of the ordinary kind might not serve, unless the blood 
state were also. ascertained. 

It is open to conjecture that {a) the fever began de novo amongst 
the starving immigrants, but see below ; {b) that sporadic cases have 
always been present in the town, without being recognised ; {c) that 
sporadic cases were imported from the Deccan, Kattiawar, Northern 
India, or possibly from Persia by sea. Either of these last suppositions 
is probable ; and, reckoning the epidemic to date from late in 1876, I 
find on analysing the hospital data of that year, amongst 35 fever cases, 



26 SPIRILLUM FEVER. 

8 like relapsing fever, 8 of doubtful character, and 19 of the usual 
remittent type. In March {i.e. eight months before the recognition of 
public sickness) the following example occurred at the G. T. Hos- 
pital : — 

Case VI. — A. D., adult, hospital assistant in the wards but sleeping at his home 
in the Kunuk (a notorious fever quarter in 1877), fell ill outside hospital, and was 
admitted March 22, 1876 ; there was then high fever of four days' standing, which 
terminated suddenly on the eighth day, the even. temp, slaking from 104° -2 (at mid- 
night the perhirbatio critica) to 97^ and subsequently lower, next morning, great de- 
pression ensuing : again, on the estimated sixteenth davof dise se, high fever returned, 
lasting six days and terminating critically ; afterwards no rise of temperature. I have 
considered the original notes and chart, and taken the evidence of eye witnesses quali- 
fied by subsequent experience to give an opinion ; and should infer that this case was 
indubitably one of relapsing fever acquired either in hospital or at home. 

Case VII. — An adult man, wandering mendicant, lately from Oude in Northern 
India, was admitted into the J. J. Hospital, April 16 1876, with fever of ten days; 
pains, diarrhoea, collapse and jaundice followed, and on sixteenth to nineteenth days a 
febrile relapse, with nervous symptoms ; convalescence protracted. There was public 
scarcity and fever sickness in Northern India at this time. Here, too, the inference 
seemed c'ear. A later example was that of a young man from Wai (Deccan), destitute, 
one month in Bombay ; had high fever with rheumatoid pains and other common 
symptoms ; a sudden fall of temp, on ninth day from 105° -5 to 98° -2, and a typical 
relapse on nineteenth to twenty-third day of disease ; thenceforward convalescent ; 
date of admission November 27, 1876. 

There are other like cases amongst individuals some weeks resident 
in Bombay, who doubtless acquired their disease in the town, about 
these dates ; the town death-rate had not then risen, and only with 
advent of pauper crowds did the fever and mortality begin to abound. 



Note on a previous Fever Sickness.' — During the years 1863-4-5, 
Bombay was visited by an epidemic even more severe than that under 
review ; numerous cases were admitted into the J. J. Hospital, where 
the diagnosis first suggested was that of typhus, caused by large im- 
migration of labourers, with consequent excessive overcrowding and 
defective food supply ; actual famine nowhere prevailed, yet as at St. 
Petersburg about the same date (1864-65) and under similar condi- 
tions, a form of recurrent typhus might, I venture to think, have been 
present (see below). I have perused with care the available records 
of this era, and agree with the earlier diagnosis rather than with the 
later one adopted of ' remittent ' fever ; it was distinctly intimated 
that the fever was the same both in and out of hospital ; and I 
find of the establishment in attendance on the sick, there died in 1864 
— female nurses, two ; vernacular students, four ; and ward boys, three; 
the remarkable experience of the years 1877-78 being thus, as it were, 
anticipated. In the town there were 12,953 deaths from fever termed 

1 The municipal records date back only to 1848, and doubtless were at first incomplete. 
There is no recollection, I found, of unusual sickness at that period ; yet it was worth 
noting that during 1848-50, Dr. Morehead saw a number of cases of remittent fever, fatal 
with jaundice ; and of those described, Nos. 54 and 56 [loc. cit. vol. i.) are, to my appre- 
sion, strongly suggestive of the icteroid form of spirillum fever. Such suggestion is 
strengthened by the fact of all these ten cases occurring in indigent subjects ; that the like 
were not seen at other dates (being extremely rare in hospital practice at Bombay), and 
that during 1877-78 specific typhus biliosus was regarded by high authority as identical 
with the so-called ' n)alignant bilious remittents.' 



EPIDEMICS AT BOMBAY. 2/ 

remittent, and during 1865 no fewer than 18,767 deaths, the previous 
equable normal mean being 6,684 yearly ; the maximum mortality 
during the worst year occurred in the hot weather months of March, 
April, and May (so in 1877) ; public sickness subsided rather abruptly 
in June 1866, that being the time when labourers commonly return to 
their country homes, and the rainy season begins. So few medical 
data were procurable that I must hesitate to express a decided opinion 
on the nature of this great calamity ; yet that it was not a malarious 
remittent may be safely assumed ; and if common typhus, the course 
and decline would be exceptional ; in a strict sense, but one inference 
remains — there being a single form of disease known which is adapted 
to explain the conditions stated. Whether or not infection could have 
been conveyed into the town was, it seems, not suggested. 



Concurrent Fever Epidemics. — This subject has been ably dis- 
cussed by the late Dr. J. L. Bryden in Chapter III. of his Statistical 
Report of 1876 (Calcutta, 1878) ; and whether or not opinion coincide 
in their interpretation, the copious data collected in this document 
claim a separate notice here, from the connection which some appear 
to have with sickness at Bombay. 

Referring to the severe local epidemic of 1863-4-5 (see above), it is 
distinctly stated by the health officer of Bombay that the fever followed 
on immigration of labourers, seeking employment on the numerous works 
undertaken during that heyday of cotton prosperity. I do not learn 
whence the labourers came ; but if custom have not changed, working 
men, especially of the weaver class, must have arrived from the northern 
provinces of India ; and, assuming this to be the case, it becomes im- 
portant to remark that, according to Dr. Bryden, in 1862-63 ^ great fever 
outbreak had occurred at Agra ; at Delhi, also, relapsing fever was 
present in 1864, and at Umballa, Lahore, Umritsur, and in Central 
India ; these being localities also named by fever patients under my 
care in 1877-78, who were likewise immigrants. The epidemic extended 
to the north of the Bombay Presidency, and is said to have been ' evi- 
dently yellow relapsing fever ' (Rep. p. 193). Some details are contained 
in the Indian Annals, 1865, of this disease as seen in Western Malwa by 
Dr. H. C. Brodrick, and in the ' Madras Quart. Jo. Med. Sc' v. ix. and x. 
there is an account of fever at Bangalore, to the south-east of Bombay, 
which had many aspects of relapsing fever ; date 1865. Further off, 
yet still in communication with the Western Presidency, viz. at Calcutta in 

1864, typhus was reported, being probably connected with an epidemic 
affecting the villages of Lower Bengal. This ' typhus ' fever was intro- 
duced into the Demerara emigration depot, some only of the coolies 
affected being from Lower Bengal, the rest from Upper India where 
typhus was raging, and they were in the depot only a few days before 
embarkation : it was also conveyed by emigrant labourers to Assam 
and to Reunion {loc. cit. p. 200). Respecting this transfer to the distant 
island of Reunion, particulars are available which tend to show the true 
nature of the imported disease ; Dr. H. Lacaze (' Union M^dicale,' 

1865, vol. ii.) stating that the fever was of a new form, distinctly con- 
tagious, and presenting many of the features of icteroid relapsing fever. 



28 SPIRILLUM FEVER. 

I am disposed to agree with him, seeing that jaundice is extremely rare in 
typhis exanthematta:S, and that 'bilious remittents ' are not contagious. 
Last y, theie is the history of a concurrent epidemic at the island of 
Mauritius, where the disease was popularly termed the ' Bombay fever,' 
from its having been introduced by immigrants from Bombay. In the 
Trans, of the Epidemiolog. Soc. of London, vol. 3, 1867, there are 
several descriptions of this outbreak of ' pernicious fever,' the general 
argument of which is that the type was that of an aggravated malarious 
' remittent. ' An Official surgeon, however, regarded the fever as ' true 
typhus' (p. 193). In the absence of detailed cases and particulars need- 
ful for strict independent judgment, I was unable to decide whether or 
not ' recurrent typhus ' was ever indicated ; but there are points named, 
which suggest this interpretation. 

Fever Epidemics concurrent with that of Bombay during 1877-78. 
Whilst it is indubitable that the great bulk of local sickness prevailed 
amongst famine-immigrants from the Deccan, there was evidence of 
famine-fever being present in the town prior to 1877, and during 1878-79 
it was commonest in subjects coming from Northern India. The reports 
of the provincial Sanitary Commissioners prove that drought and fever 
of a severe type were widely prevalent at this epoch. In the Punjaub 
fever was of continued character and not due to malaria, relapsing fever 
being distinctly recognised in 1876-77 ; here mortality was even more 
excessive in 1878, relapsing fever proving very fatal in the southern 
districts, especially in the towns and rural circles to the south of Delhi 
(whence many of my patients directly came) ; there was not then actual 
famine, but the poorer classes were much distressed for food and suffered 
from unusual hardships : that true typhus existed was clearly demon- 
strated in some parts. In the North-Western Provinces and Oude, fever 
was unusually prevalent and fatal during 1876 ; in 1877 there was much 
at Lucknow and other large towns, of continued type : typhus, relapsing 
and enteric fevers are expressly recognised : in 1878 the existence of 
contagious fever is also admitted. In Bengal during 1877, fever became 
epidemic in certain districts ; at Midnapore the attacks seldom lasted 
more than three days, but relapses frequently occurred after a week or 
so, the disease being widely different from the epidemic of 1871-76; and 
at Serampore, with overcrowding and dearness of provisions, fever arose. 
In the Central Provinces nearer Bombay, mortality from this cause was 
high in 1876, also in 1877, and still more during 1878, when in the most 
affected district of Nimar, the presence of non-malarious relapsing fever 
seems to be clearly indicated; cases being seen not only amongst ema- 
ciated and starving subjects, but also prisoners admitted to gaols, and 
at all the dispensaries. Migration from this part to Bombay by rail is 
known to have taken place largely. 

In sum, there is conclusive testimony of widespread and severe fever 
sickness in other districts than the Deccan, whence also the facilities of 
communication were considerable. The need of precise clinical details 
and diagnosis, may be keenly felt during the perusal of the official Re- 
ports ; nor, must it be added, were the opinions of the writers uniform 
on even fundamental points. 



HISTORY OF RELAPSING FEVER. 29 

General History of Relapsing Fever. — A comparison of late 
events at Bombay with the Irish epidemics of 1846-50, naturally suggests 
itself : and on referring to original documents, I find much to indicate 
that with identity of certain conditions, there may have been a partial 
identity of disease. It is understood that the Irish fever was mainly of 
the relapsing kind. 

In the late absence of famines in Europe, data still exist for com- 
parison with the Bombay epidemic of 1863-4-5 ; e.g. the history, which 
I have also considered, of events at St. Petersburg during 1864-65, dis- 
plays even a precise similarity of originating influences. Fever was said 
to be imported into the city, Moscow being mentioned in this connec- 
tion ; relapsing fever was at Odessa in 1863, at Riga in 1865, and, more 
noteworthy, it then prevailed in Kasan, the most easterly province of 
Russia in Europe (E. long. 60°, confines of India 70°). Information 
regarding countries further East, is necessarily wanting; yet, bearing these 
concordant dates in mind, an impression arose which must have occurred 
to others than myself, since Dr. A. Hirsch ('Handb. d. Hist. Geogr. 
Pathologic,' Stuttgart, 1881) alludes to the possibility of there being a 
central focus of relapsing fever in Asiatic provinces lying between Russia 
and India. • The existence of such a focus is not, however, essential to 
the comprehension of long conveyance of this disease. 

Analogy here with the natural history of Cholera must be obvious ; 
this transportable malady having pursued a course similar to the one 
suggesting itself for Spirillum fever. 

There only remains to remark that, contrary to some early anticipations 
of physicians, the most strictly epidemic of human fevers, on the continent 
of Europe now displays a tendency to become endemic (to be ' natura- 
lised,' as expressed by the late Prof. Lebert) ; and, supposing that re- 
lapsing fever were not already indigenous there, it remains to be seen if 
its endemicity be or be not established at Bombay. I possess the notes 
of cases extending from early in 1876 to the beginning of 1881. 

For other remarks on the epidemiology of Spirillum fever, see 
Section III., Chapter Ty- 

' Dr. Morache (Recueil d. M^m. de M^d. milit. fevr. 1866) has briefly described a 
mild epidemic of typhus ' with cases of relapsing fever ' observed at Pekin during 1864-5, 
or about the time when so much identical sickness broke out at St. Petersburg. The 
author insists upon these simultaneous dates, and states that the fevers might be traced 
eastward across Asia as far as Kiakhta on the Chinese frontier ; the sanitary condition of 
Mongolia was not known, but in the North of China proper typhus and relapsing fever 
seem to have been recognised. There had been an inclement winter, and the people had 
suffered. Typhus and enteric are said to be common in Chinese towns and villages ; the 
relapsing fever element was identified by Dr. Morache upon the receipt from Paris of 
medical intelligence respecting the new fever at St. Petersburg, and previously it had been 
considered as a form of typhus. Here may be remarked the utility of promptly dissemi- 
nating fresh clinical knowledge ; and especially noteworthy is this additional evidence of 
a great epidemic epoch dating about 1863-5. 



30 SPIRILLUM FEVER. 



EXPLANATION OF CHART No. i. 

Column A. — The numbers of individuals on relief works is the total present in 
last week of each month : the decline in February was incidental ; the brief rise in 
September was dug to apprehension of renewed want, from defeciive rainfall. In 
1878, the daily maximum of relieved amounted to 19,544, and in 1879 to 17,656. 
No relief works prior to 1876. 

Column C. — The light-tinted bars from 1877 onwards are the means of actuals in 
1875 and 1876, being superadded to show better the actual excess of deaths (black- 
tinted bars) during 1877, 1878, and 1879. These means for the months in order are: 
January, 8,563, 7,354, 8,071, 8,929, 9,933, 9,205; July, 11,555, 12,441, il,33l. ■ 
10,023, 10,662, and 10,678: sum 118, 745. Yearly actuals — 1875, I19910; 1876, 
116,570; 1877, 223,388; 1878, 201,418; 1879, 129,840. Augmented mortality is 
seen to have begim shortly after the recognition of public distress ; prior to June 
there was much emigration from these distrcts ; after June many returned : similar 
movements in 1878. In 1879 the epidemic seems to have become exhausted here. 

Column C. — The pale bars for 1877 onwards are the means of actuals in 1875 and 
1876, being superadded as in Col. B. These means in order are for January onwards, 
535) 5") 523, 500, 466, 409 ; July, 382, 400, 383, 405, 481, and 550 : sum 5.545. 
Yearly actuals— 1875, 5,244; 1876, 5,867; 1877, 12,832; 1878, 9,944, and 1879, 
8,445. The augmented fever mortality is seen to have begun aloout the same time as 
distress in the Deccan, and to attain its maximum in the main famine year of 1877 at 
nearly the same time ; this being also the date of largest immigration from the affected 
districts. Slow decline of this excess is referable, partly to townspeople becoming 
implicated, and partly to immigration of paupers from oth€r districts than those of the 
Deccan ; this cannot be shown here. 

Column D.— The admissions are those of so-called remittent fever, there being no 
recognised heading for famine-fever. The pale bars indicate as in Cols. B and C, the 
normal means for 1877 onwards being as follows — 13, 14, 15, 19, 12, 13, 13, 14, 19, 
28, 36, and 22 : sum 218. Yearly actuals— 1875, '75 ; 1876, 267 ; 1877, 1,073 '■> 1878, 
639, and 1879, 273. The augmentation of fever admissions, in 1877, is contemporary 
with the recognition of public distress (Col. A) and with the excessive mortality of 
Cols. B and C ; its persistence and the rise, in 1878, are due to influences not shown 
in this Chart ; see Col. C and the text. 

Column E. — The earliest appearance of undoubted famine, relapsing (or spirillum) 
fever may be indicated by the dotted line : the max mum numbers, in 1877, corre- 
spond with fever admissions in Col. D — the earliest being contemporary also ^\\\\plus 
fever-deaths in Bombay sxiA. plus public distress in the Deccan. In 1878 fresh races 
and castes furnished many cases of fever {vide Cols. C and D) which were now discri- 
minated with care. The decline of specific fever at the J. J. Hosp'tal in 1879, as 
here shown, requires to be supplemented by experience at the G. T. Hospital [vide 
the text), when it will be found to correspond better with fever-deaths in the town 
at same dates. 



ChartN?!. 



CHART 


OF COFiRELATED DATA OF THE. LATE FAMINE AND FEVER SICKNESS. BOM BAY PRESIDENCY : BRITISH INDIA . 1877. 


YEAR 


MONTH 


PAUPERS AT l=0VtKNMtN7 RtL tF WORKS COL i 


B ,rM FEVE.RFAM NEOSIBf 


C DEATHS FROM FEVER BOMBAY C rv 1 


FEVERCfcSES J J fOSP TAU 


EcasesofFAHINE fever, jjh. 




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. yj /i/<--C.i- rjj/f/ot'/ ri,i.i7/e!i/i//-su:vna-^-: 77^ j,-/i<i(^^i'<I iiuCt'^- (-'(iil//uij'a/id,AJai/t s/chtess. 



H.V.CARTER Prl 



31 



SECTION II. 

CLINICAL HISTOR Y OF THE SPIRILLAR INFECTION. 



CHAPTER I. 

SOURCE AND SUM OF DATA. 

By an excellent regulation the medical officer in charge of sick should 
enter daily, in printed forms, the state and progress of every patient 
under his care ; and I am bound to state that this injunction was faith- 
fully carried out, under circumstances of unusual stress, at the hospitals 
under my superintendence. Considerable advantage, too, at the College 
Hospital was derived from the more elaborate records of the Clinical 
wards ; where under the eye of able and experienced teachers, many 
special details were elicited. Investigation by means of the microscope, 
as an extra-official work, had to be separately performed ; and in this 
I had the willing and valuable assistance of Mr. Succararn Arjoon and 
Dr. A. M. Kuntay. It was my practice to see personally every ' fever ' 
case on admission, and then to examine the blood ; and had this not 
been done, many useful data would have been lost. Owing to the large 
amount of current duty arising from the excessive public sickness, 
scientific research was necessarily deferred ; and the prior object being 
to estabhsh the diagnosis of this new disease upon a wide and adequate 
foundation, little time was left for particular enquiry : afterwards, 
attempts were made in this direction. 

Sum of Data. — The materials collected at the J. J. Hospital between 
May 1877 and December 1878, comprise notes of 1,249 cases of remit- 
tent fever (so-called) ; in 339 of which the blood was not examined 
for want of opportunity or from the absence of defined symptoms 
(Class A) ; in 401 the blood-spirillum was not found upon microscopical 
scrutiny (Class B)— both these groups including, besides remittents, 
some instances of symptomatic pyrexias retained for the sake of com- 
parison. The remaining cases, amounting to 509, all displayed the 
blood-parasite ; and it is upon this group (Class C) that the following 
clinical details are mainly founded. 

At the G. T. Hospital, during the intervals of my tenure of office, 
no cases of Spirillum Fever were seen ; and also a large number of 
other cases, which have been employed as data for the section on 
Remittent Fever. 

At both these hospitals the officers in charge, permanent or tern- 



32 SPIRILLUM FEVER. 

porary, likewise made special investigations ; with the result of confirm- 
ing and continuing the present series of positive data. 

It has been previously stated that at the Camp of Refuge opened in 
April 1877, several cases, and the earhest of all, of genuine famine-fever 
were made known. 

Thus, the entire number of certified instances of specific fever of 
which the notes are available, amounts to 650 ; and in 624 of these the 
main particulars were entered personally, or under my own inspection. 

General Character of Data. — Partly for future guidance, it will be 
useful to mention past experience under this heading. According to 
European standards, the hospital accommodation at Bombay is very in- 
adequate (there being only 600 beds to more than half a million of 
people) ; but, owing to various prejudices, it is not the Native custom to 
resort early or freely to European medical aid ; and new comers from 
the interior were more than usually indisposed to seek for admission. 
Hence very few instances of relapsing fever were seen at the beginning 
of illness ; and almost always a week or so had elapsed before our help 
was sought. This circumstance was peculiarly unfortunate, since this 
period is about the mean duration of the first attack, and if the case 
were not promptly diagnosed, its nature might remain obscure for 
another week (till the relapse set in) ; or in case of early decease or 
absence of relapse, it might never be strictly verified. Commonly the 
last day or two alone of invasion were witnessed, when alarm at the 
rising symptoms induced the friends of the patient to seek for aid ; and 
sometimes it was the equally alarming state at critical fall which impelled 
them : many cases were not brought until it was evident that con- 
valescence was being checked by accessory fever or local complication ; 
and, finally, there might be available for analysis only the history of 
a late febrile attack to account for anomalous symptoms or general 
prostration. These deficiencies were, however, to some extent made 
good by the many instances of contagion in hospital, which happened 
at intervals throughout the epidemic ; and which usually displayed the 
entire specific illness. The first apyretic interval and recurring attacks 
of fever were abundantly illustrated ; but the latest stages and ultimate 
effects of infection were less well displayed, as patients usually insisted 
on leaving hospital with returning convalescence ; this defect is not, 
however, entire ; and, generally, it is probable that all the chief modifica- 
tions attending the late epidemic, did in course of time pass under 
observation. 

Lastly, owing to prejudice of relatives, autopsies were sometimes 
impracticable when it was very desirable they should be made ; yet so 
many friendless subjects reached hospital, that nearly adec^uate informa- 
tion of structural changes became available. And after making due 
allowance for the local circumstances impeding full enquiry, there still 
remains a collection of evidence, which, I think, may fairly rank with 
most European data acquired with more adventitious aid. Every one 
of the records made use of in the present work is still open to in- 
spection, and each has been carefully and repeatedly scrutinised ; for 
of all none has proved uninstructive or useless for analysis, if only 
rightly used. 



33 



CHAPTER 11. 

DEFINITION AND CLINICAL SUMMARY. ILLUSTRATIVE CASES. 

Definition and Designation.— Pathologically, as well as clinically, the 
spirillar disease should be regarded in its entirety ; and thus viewed, it 
presents both febrile and non-febrile phenomena. 

Inevitably, the complex pyrexial state has attracted most attention^; 
and by it, the infection is currently known as a peculiar kind of ' fever.' 
Yet in order of time, such fever is but the culminating event of a 
prior non-febrile period of blood contamination ; which, though offering 
comparatively few symptoms for clinical notice, is yet an essential part 
of the disease, and constitutes the so-called 'incubation-stage.' 

The spirillum ' fever,' in man, is remarkable for its tendency to recur 
at tolerably regular intervals ; its successive febrile repetitions becoming 
gradually less sustained, and the intercurrent non-febrile stages more pro- 
longed : in this way, whilst relapsing the disease spontaneously declines. 
For convenience, the febrile events are in order of succession named 
the first or ' invasion ' attack, the second attack or ' first relapse,' the 
third attack or ' second relapse,' the fourth attack or 'third relapse,' and 
so on. Of the antecedent non-febrile periods, the earliest, or that pre- 
ceding invasion, does not commonly come under notice ; the second, 
or that intervening between invasion and first relapse, is here termed 
' the first apyretic interval ; ' the second, coming between relapses one 
and two, is the ' second apyretic interval ; ' and the third, between relapses 
two and three, is the ' third apyretic interval.' 

As to clinical variations of the disease, whilst the invasion is always 
pronounced, the relapses differ considerably in intensity ; and most so 
the later. Sometimes there is no palpable recurrence of fever after the 
first attack (which has then been termed ' abortive '), or only a slight 
periodic indication (' suppressed ' or ' latent ' relapse), a similar indica- 
tion oftener, however, standing in place of later recurrences : commonly 
one distinct relapse takes place ; occasionally a second, and still more 
rarely a third or fourth. 

All pronounced pyrexial events present well-defined limits and high 
range of temperature, a rapid pulse, severe body-pains, and especial 
implication of the viscera in the upper abdominal zone. The apyretic 
intervals represent a quasi-normal condition of the frame. Visible 
blood contamination by the spirillar organism is at first scanty, and 
becomes increasingly evident during fever ; until the acme of attack, 
when both blood infection and pyrexia abruptly cease. 

In early and severe attacks, about this acme-epoch local accidents 

D 



34 SPIRILLUM FEVER. 

(such as hsemorrhages) are apt to arise ; and other complications (as 
secondary fever and local inflammations) commonly date thence, or 
immediately afterwards. Death from fever is usually referable to the 
same time ; and with all these events, certain blood changes concur. 
Sequelse are not very common. 

So far as yet known, the spirillar disease is always acute. This 
infection is said to arise spontaneously (in a clinical sense) oftener than 
some other acute infections ; but, once developed, it is decidedly con- 
tagious. A close, if not absolute, relationship exists between presence 
of the spirillum and manifestation of constitutional symptoms. 

Clinical Designation. — Having become assured by unprejudiced 
observation, that the late Bombay fever is not only a veritable species 
of disease, but also identical in character with the 'relapsing' or 
' famine-fever ' and the ' recurrent typhus ' of Europe, I consider it 
desirable to adopt a more exact designation for this affection, on the 
following grounds : — Practically, a considerable proportion of surviving 
cases in man did not relapse ; and, as a rule, but one attack was pro- 
duced by inoculation of the Quadrumana ; both these data pointing 
to the presence of a simple and, therefore, fundamental character of 
the infection in question. Moreover, according to my experience, most 
fatal cases do not attain the recurrent stage ; and had their diagnoses 
rested on such relapsing feature, it could not have been accurately 
made. 

Next, by far the largest proportion of cases, could not be said to 
result from starvation. Further, the term ' typhus ' has in England 
acquired a definite meaning it is not needful to disturb ; nor does the 
Continental expression convey a thorough generalisation. To continue 
to apply to this disease the name of ' remittent fever ' would be, I may 
add, to ignore the progress of clinical medicine ; and to increase a 
confusion of nomenclature, already embarrassing in practice. 

Lastly, through many early perplexities having learnt the value of 
one characteristic, the presence of which was a never-failing guide to 
diagnosis, prognosis and treatment, I was in a measure impelled to 
adopt, as a synonym of relapsing or famine-fever, the cognomen 
' spirillum fever,' which, whilst not excluding the appropriate use of 
current terms, will be found to apply where they are unsuitable. 

Thus used, the word ' spirillum ' stands provisionally for an organism, 
not entirely answering to accepted generic definitions of either ' spirillum ' 
or ' spirochgete.' 

Description of the Disease. — The following summary account is based 
on records made chiefly during the height of the epidemic ; it refers to 
the successive febrile and non-febrile phenomena as commonly wit- 
nessed, with their general features, variations, complications and sequelae. 

First or Invasion Attack. — Prodromata were seldom recognised 
with certainty : those named amount to a sense of malaise felt shortly 
before the onset of fever (see the next Chapter). The blood-spirillum 
is probably always present, though scantily, at this time. 

First day of illness. — Has been seen almost exclusively amongst 



CLINICAL SUMMARY. 35 

servants, or patients who were seized with fever in hospital. Twelve 
such records are available for analysis, all of which contain the initial 
temperature and the pulse, but sometimes Httle more ; because the true 
nature of the attack not being always recognised at first, brief even- 
ing notes alone were recorded. 

Hour of invasion. — Twice this was not certain, on account of there 
being some premonitory mild or irregular pyrexia ; of the rest, fever set 
in just before or commonly after sunset in eight, and in two only was 
it observed first at the morning visit. 

In all cases the onset was defined, and in most abrupt ; pyrexia may 
or may not be attended with the subjective symptoms of chilliness, not 
amounting to rigors ; severe headache (usually frontal) and pains inthe 
spine and limbs, with a sense of weakness and indisposition for exertion; 
thirst, a coated tongue, and dry mouth ; loss of appetite, nausea, or 
vomiting ; costive bowels and a dry skin speedily follow ; the counte- 
nance may even now become dusky, and indicative of oppression. 
Soreness and tenderness of the upper zone of the abdomen have been 
observed at this time, and twice at least the liver was enlarged ; the 
condition of the spleen, which it is more difficult to ascertain when 
changes are only beginning, was seldom accurately learnt ; but once at 
least the organ was sufficiendy enlarged to project beyond the costal 
margin ; the epigastrium is affected with uneasiness. 

Though pyrexia be considerable, patients are not necessarily pros- 
trated ; thus, a native student on this day was found writing in the 
wards, with a temperature of 103° and his blood charged with the 
spirillum; and in my own attacks, by dint of great effort, the strong 
feeling of oppression was overcome for a few days longer, subsequent 
depression being possibly augmented by such effort. Children, and 
especially infants, seem to suffer little at first ; the latter seek the breast 
as usual. 

Pyrexia. — The mean evening temperature was 103° -2 when fever 
came on in the afternoon, and 104° -5 when it came on in the morning ; 
in the last-named instances the temperature at 7 a.m was io3°-2, and 
there was usually a history of fever in the previous night, which doubt- 
less represented the true initiation of the attack ; an abrupt ascent of 
6° was noted in two out of six cases of afternoon initiation, and there is 
reason to believe that the rise at evening, which is practically invariable, 
may continue during the earlier part of the night. Considerable uni- 
formity in these initial rises is noticeable in the mild typical cases under 
notice ; the maximum morning temperature on the first day was io3°"8, 
with 105° in the afternoon ; the maximum initial evening temperature 
was io4°-2. The minimum temperature noted on this day was 102° in 
an infant. 

The absolute initial rise was, in the mean, 4° 7 in the morning, and 
4° -9 in the evening onset, which shows how nearly alike the temperature 
is at 7 A.M. and 4 p.m. of the first day of attack. 

In two fatal cases occurring amongst the hospital establishment, the 
precise date of onset was obscured by paroxysms of intermittent character 
which were not specific ; and in two other instances out of thirteen 
there was a single aguish attack immediately before the commencement 
of persistent fever ; such attacks have been noticed also ten, fourteen, 



36 SPIRILLUM FEVER. 

and twenty days prior to specific invasion — their significance is not 
clear. 

Pulse. — Shows variations considerable, and seemingly dependent 
upon personal idiosyncrasy, sex, or age. The mean of initial morning 
temperature being io3°'i, that of the pulse is 112, and initial evening 
attack 116, the temperature being also slightly higher. No fixed rela- 
tion of pulse and temperature is noticeable ; though on this day the 
evening pulse, like bodily heat, is usually higher, and never lower, than 
in the morning. The cases under review display an unusually rapid 
pulse in woman and child; and, on the other hand, a sluggish pulse in 
two men out of seven. For example, a child with initial evening tem- 
perature of 102° had a pulse of 124, and a woman with a similar morn- 
ing temperature a pulse of 114 ; whilst a man with initial morning tem- 
perature of 1 03° -6 had a pulse of only 96, and at evening (105°) of 106 
only; and another man with an initial evening temperature of 104° -2 
had a pulse of 104, which contrasts greatly with a third who, under an 
evening temperature of 104° "6, had a pulse of 136. Putting aside ex- 
ceptions, the average pulse of adult men on this first day may be 120, and 
that of women and children slightly more, the temperature being about 
the same for all. 

The quality of the pulse is expressible thus early as soft or compres- 
sible, even if rather full, and it is sometimes also small. 

Second day. — The pyrexia is but slightly abated, the mean morning 
temperature in these same cases being io3°-i, that of evening io3°-3 ; 
in half the cases the morning temperature was slightly higher than 
that of evening, doubtless from exacerbation during the night. The ex- 
tremes of morning temperature were i o i ° '4 and 1 04°, the extremes of even- 
ing temperature 102° "4 and 104° '4, being steadiest as well as highest. 

The pulse follows the temperature, and it shows even more strongly 
in its frequent morning excess, the disturbing influence of the febrile 
invasion ; thus the morning pulse may be quickest even when the morn- 
ing temperature is below the evening temperature ; but I should add 
that the reverse obtains sometimes, and the inference from these obser- 
vations would be that the pulse both rises more promptly and subsides 
more slowly than the bodily heat, as commonly measured, in response 
to the hidden pyretic influence of this form of fever. It is marked as 
small and feeble. The mean morning pulse was 124 ; that of evening 
about 118 ; and while admitting that the rapidity of the pulse is liable to 
many contingencies, still this statement has its import. In the bi-daily 
readings under analysis, evidence of minor pyrexial movements is 
necessarily absent, but such movements are known to occur. 

The headache often increases, and may be intense, without regard to 
temperature and pulse ; injection of the eyes is noted; the coated tongue 
is still white and moist, but in a case of typhus tendency it was dryish ; 
the bowels are costive, thirst is considerable ; the liver and spleen are 
full and tender ; the pains continue ; the skin was dry only twice ; 
nausea and vomiting were sometimes present in the morning, in con- 
junction with severe headache ; the sleep is disturbed ; the urine was 
noted as scanty, specific gravity 1016, reaction acid, no albumen. 

Third day. — The pyrexia is decided, but the morning remission is 
now constant, and perturbations due to the invasion disappearing, the 



CLINICAL SUMMARY. 37 

evening rise becomes invariable. The mean morning temperature is 
io2°-4, that of evening temperature 103° -6 : the maxima respectively 
1 04° -8 and 103° -6 ; the minima 101° '2 and 101° -8 (which last is ex- 
ceptional). 

The pulse has become slower, the morning mean being 112, the 
evening 116 ; it is less sensitive, yet the morning pulse is not very 
seldom quicker than might be anticipated from the consentaneous tem- 
perature ; instances of unusually slow and rapid pulse are noted. 

The headache persists, but may abate, it seems to hold no fixed 
relation to the pyrexia ; the tongue is in the same state, a florid tip and 
edges is entered ; bowels require aperients ; thirst is great ; the liver is 
usually large and tender, three times in fifteen it alone was implicated, 
whilst the spleen, usually affected in the same way, was alone changed 
twice ; the uneasiness in both these organs is liable to be increased upon 
deep inspiration, or in the act of coughing, and the whole abdomen is 
often full and tender ; not excepting the hypogastrium, where especial 
uneasiness, without distension of bladder, may sometimes be felt ; the 
aching pains are great, particularly in the loins and lower limbs ; the 
state of the skin varies ; vomiting is noted, concurrent with febrile 
exacerbation ; appetite impaired ; sleep wanting, even if little or no head- 
ache ; cough (bronchitic) now appears in some instances, and jaundice 
is noted, with more frequent or marked hepatic congestion ; epistaxis 
happened once. The urine had a specific gravity of 1017, was acid 
in reaction, and contained no albumen. 

Fourth day. — In about fifty cases submitted to analysis, the pyrexia 
offered several variations, which referred chiefly to depressions occurring 
in the early morning ; the most typical series was one of twenty- two 
cases, furnishing the following results : — Morning temperature — mean 
103°, max. 104°, min. ioi°'6, range 2°'4. Evening temperature — mean 
104°, max. 1 05° "4, min. 102° "6, range 3°. With one exception the even- 
ing temperature was equal to or in excess (usually) of the morning 
temperature, so that now the prolonged effect of nocturnal exacerbations 
is rarely perceived next day. Pulse — at morning the mean was 113, 
max. 125, min. 94. At evening, 117, 130, and 108 ; so that the pulse 
responds freely to degrees of pyrexia, and it, too, was once only quickest 
in the morning. 

In two other series of cases the mean temperature was somewhat 
lower, but not generally the pulse ; the relations of pulse and tempera- 
ture, which on the whole are uniform, may be disturbed by exceptional 
instances, wherein the pulse is either sluggish or irritable; its debilitated 
character was marked, with one exception where there probably co-existed 
hypertrophy of the heart. 

In four out of twenty-two types, the critical subsidence of pyrexia 
took place upon this day ; they were all very mild cases. 

The general symptoms undergo little modification, but some changes 
are noted ; thus, headache may be mitigated ; the tongue tends to dry- 
ness, with a brownish fur ; there may be diarrhoea ; thirst is very pro- 
minent ; the liver and spleen are persistently implicated ; the pains 
are about the same ; the skin is dry when fever is persistent ; vomit- 
ing is noted ; the appetite continues impaired, with an occasional 
exception, when hunger is expressed ; no sleep ; cough is more frequent 



38 SPIRILLUM FEVER. 

(congestive) ; the peculiar faciei of the disease is well marked, and in 
general there is augmenting weakness, emaciation and distress. In the in- 
stances of crisis headache had subsided, the tongue was coated white or 
brown, there was vomiting, once epistaxis ; the spleen continued large, 
there was exhaustion, a feeble pulse, and, in all, the body was covered 
with clammy sweats. 

The urine had a specific gravity of 1010-18; chlorides varied from 
I" to ;^ the volume, and there was a trace of albumen once in three cases 
examined. 

Fifth day. — In these ordinary examples the pyrexia remained con- 
stant, but there is a tendency to vary. The temperatures were as fol- 
lows : — Morning — mean 103°, max. 105° -3, min. 101° -8, range 3° "5. 
Evening — mean 104°, max. 105° '4, min. 102° "4, range 3° "6 ; individual 
cases show a nearer approximation of temperature early and late in the 
day, so that the pyrexia appears more continuous in character ; very 
seldom the morning temperature was slightly higher than the evening 
temperature. The pulse shows a decided increase in frequency, so that 
it may be said to rise with the progress of the fever ; for morning the 
mean, maximum and minimum were 118, 147, 100; and for evening, 
123, 142, 100; as the morning pulse may be augmented when the 
temperature is not so, it appears that its irritability is again increased, 
so that the influence of nocturnal pyrexia becomes perceptible once more. 
In three of twenty-two cases the critical fall occurred this day, and 
then twice in the morning. 

As to general symptoms, the headache may be increased, the tongue 
brown and dryish, thirst follows the temperature (very rarely it is les- 
sened) ; the liver is not freshly implicated, but the splenic enlargement 
may be now first noted ; pains are more frequent ; partial sweats have 
been noticed ; vomiting and epistaxis are rare ; cough is not more fre- 
quent ; jaundice may be present ; sleep is disturbed, and a new symptom 
appears, namely delirium at night (two in twenty-two cases). 

The urine has been noted as scanty, specific gravity 1015, chlorides 
deficient, albumen absent. 

Sixth day. — The fever is somewhat higher and more irregular, being 
often disturbed in its more or less level and continuous course by ap- 
proach of the crisis, when 2l pertiirbatio critica is observed. The tem- 
peratures were as follows: Morning — mean io2°*5, max. io4°'6, min. 
ioo°'6, range 4°, Evening — mean io3°-8, max. io5°'8, min. ioi°*8, 
range also 4°, with a tendency to morning remission ; the rise at even- 
ing, always present, is often considerable {i.e. 2° or more), but vacilla- 
tions are noted so often that the mean evening temperature is slightly 
below that of the fifth day. The pulse almost reverts to its condition 
on the second day, showing, namely, a tendency to excess in the morn- 
ing, or to equality with the evening pulse, which, on the other hand, 
exceeds in frequency in barely half the cases ; the means, maxima and 
minima, of the pulse at morning and in evening respectively, were as 
below : Morning, 118, 136, 100 ; evening, 117, 142, and 105. 

General symptoms. — Headache may be less; the tongue tends to dry- 
ness, with a brownish fur; bowels vary; more thirst; liver and spleen full 
and tender, the left lobe of the liver maybe especially affected; vorniting 
rare; epigastric uneasiness varies; aching pains are usual; skin is harsh, or 



CLINICAL SUMMARY. 39 

dry ; appetite has several times been noted as considerable at this time; 
sleep disturbed ; pulmonic congestion not increased ; jaundice same ; 
epistaxis may occur, dilated pupils and depression ; during acme at this 
time, rigors, restlessness, and sweats may appear, or acute delirium, 
which is, however, rare. The state of the urine has varied somewhat ; 
the specific gravity from 1015 to 1018, scanty or free, high coloured, 
acid, rarely a trace of albumen ; chlorides and bile pigment are pre- 
sent, the former from ^ upwards. Exhaustion is still partly hidden 
by the pyrexia, but is manifested in the pulse. 

In one-fourth of a small series of types the fall took place this day 
oftenest in the morning. 

Seventh day. - Amongst ordinary cases reaching to this day, the 
pyrexia generally is less marked than on the previous day ; whence it 
appears that the longer duration of the fever does not entail its greater 
intensity. The temperatures were as follows : — Morning — mean io2°_-4, 
max. io5°-4, min. 99°"8. Evening— mean io2°-3, max. io5°-2, _min. 
99°-8. The range for both times was 5°-5, but variations in individual 
cases are so considerable that the mean ratios are of limited value ; 
and that of evening temperature would be higher if the crisis had not 
sometimes already commenced ; in this series there is no rise of striking 
importance. The pulse also varies considerably, and that owing chiefly 
to the impending critical fall. Morning pulse — mean 108, max. 130, 
min. 96. Evening pulse — mean in, max. 1 24, min. 94; there is little dif- 
ference between the pulse of morning and evening, though the morning 
temperature is slightly in excess ; yet the morning pulse is rather less, 
showing that the pulse is more sensitive than temperature, and now rises 
and falls quicker than before ; it would seem that the fall of pulse pre- 
cedes that of temperature as the period of crisis draws nigh ; dicrotism 
is noted. 

General symptoms — headache may increase ; the tongue may be 
less dry, the mean temperature being lower ; thirst continues ; diarrhoea 
may set in ; the liver and spleen are not more affected, and enlargement 
of the latter has been noted as going down ; aches are less ; the condi- 
tion of the skin varies with the movements of fever, sweats attending the 
remissions ; bilious vomiting is noted ; appetite mostly indifferent, or 
bad ; cough is not usual, but pulmonary congestion may end in some 
degree of basal consolidation ; jaundice comes on sometimes ; abdo- 
minal uneasiness may be severe. Delirium is commoner (one-fourth 
of cases), and \ht perturbatio critica at this period may be marked. The 
urine varies in amount ; its specific gravity is still low,' 1010-18, no de- 
posit, no albumen ; when depression is considerable it may be passed in 
bed. 

In nearly one-half of the instances the crisis occurred on this day, 
and oftenest in the evening. 

Eighth day. — In a series of ordinary cases known or estimated to 
have reached this date, one-third only had pyrexia, which was hardly as 
high as on previous days. There is a tendency to equability of morning 
and evening temperatures, partly due to decline of the latter, in antici- 
pation, as it were, of the fall next day. The means were 103° -4 
(morning) and io3°-9 (evening), with a range of 2° or 3°. The pulse 
is also rather slower, and its evening excess less marked ; it follows the 



40 SPIRILLUM FEVER. 

temperature when this is materially higher in the earlier part of the day, 
and its irritability seems to be lessening, possibly by cardiac exhaustion; 
morning, 109 ; evening, 113. 

General symptoms. — On the whole there is a significant absence of 
sthenic or severe symptoms, proportionate to the high pyrexia which 
may obtain ; headache persists, and the conjunctivae are injected ; 
tongue coated, not necessarily dry (most patients drink frequently) ; 
thirst is present ; the liver and spleen are not more affected, or pains 
greater, except on movement ; abdominal uneasiness may be consider- 
able ; delirium not more frequent, but depression and the facies marked; 
\he perturbatio critica is not common. 

In one-third of the instances under notice crisis took place in the 
morning of this day. 

Ninth day. — A few selected cases now remain in which the duration 
of the fever is stated with precision to be nine days, or longer ; such 
have not been witnessed amongst the instances of contagion in hospital, 
but they seem to occur. The mean temperatures are high and uniform, 
being 104° morning and 105° evening, and this close upon the critical 
fall. The pulse, on the other hand, tends to become slower, the means 
being 11 1 morning and 112 evening per minute ; it is always soft and 
usually small. 

The general symptoms were not exacerbated, and may be even less 
severe, though debility becomes marked ; the liver and spleen are less 
tumid and painful ; sweats are not uncommon ; the perturbatio critica 
was not noticed in this small series ; urine, specific gravity 1018, neutral ; 
chlorides reduced (^), no albumen, quantity moderate. 
Crises happening on this day were in the evening. 
Tenth day. — As reported, in these rare instances the pyrexia was 
commonly abated, the mean temperatures being 102° morning and 
io3°7 evening, and the pulse loi and no. 

General symptoms. — In severe cases headache persisted, thirst was 
marked; sleep disturbed, pulmonic congestion was noted, also jaundice ; 
the liver was tender and large, the spleen not so ; a trace of albumen 
was noticed in the scanty, high-coloured urine, specific gravity loio, with 
bile ; partial sweats occur. Delirium, most marked at night, is usual, 
which is a noteworthy feature ; debility considerable. Decided hunger 
was expressed when high fever persisted ; aches were common. 

Critical fall took place in the evening, but was not particularly marked ; 
it was rather prolonged, showing a tendency to lysis. 

Eleventh day."^ — In rare cases the crisis was deferred until the morning 
(usually) or evening of this day. The depression was then considerable, 
temperature being 96°-5 and pulse 79. The general symptoms had been 
well marked, and especially visceral compUcation, of the liver oftenest, 
which still persisted at the fall. Delirium was sometimes present, and 
headache continued. The urine was found to have a specific gravity of 
I GIG, and to be free from albumen. 

The Crisis. — In the evening or during the night of the sixth or seventh 
day, there usually happened a brief augmentation of all the symptoms, 
with the addition of some delirium {perturbatio critica) ; and immediately 
after a complete reversion of symptoms takes place at this time, in the 
course of six to twelve hours the condition of the patient becoming 



CLINICAL SUMMARY. 4I 

totally changed. This typical crisis is almost invariably attended with 
copious perspiration, which, beginning before the decline of the pyrexia, 
may persist long afterwards. The fall of temperature amounts to 5°, 7°, 
or 10° R, and in the morning the body-heat is 97°, 96°, or less ; defer- 
vescence is most rapid at first ; it may end in a condition approach- 
ing to collapse. The pulse also now declines, but not so promptly as 
does the temperature ; it becomes small and feeble, and may be inter- 
mittent ; the number of respirations also diminishes, though not yet 
to the normal rate. 

Relief is at once experienced by the patient, the headache and abdom- 
inal uneasiness subsiding ; deep sleep follows, the tongue speedily 
becomes clean, and excepting debility, there may be little peculiar to 
note. Occasionally, however, with extreme muscular weakness, coldness 
of surface and cardiac exhaustion, there are indications of nervous de- 
rangement and even delirium, with no evidence of vascular cerebral 
excitement ; the pupils are not contracted, and the skin remains cold 
and clammy ; the urine is copious and pale, and, in short, there has 
ensued a condition which, in my experience, is almost pathognomonic 
when taken in connection with the previous history. Patients were not 
rarely brought to hospital in this state. 

I have many times verified the statement that the blood parasite 
suddenly disappears from the blood at, or just prior to, the critical termi- 
nation of fever. 

The aspect of the patient in severe cases is one of sheer exhaustion ; 
the features are shrunken and wan, and the voice feeble almost as in 
cholera. Crisis by diarrhcea was extremely rare, yet the fall was then 
pronounced ; by haemorrhages alone, it was never witnessed. 

Commonly with cessation of fever and repose, a prompt reaction 
takes place, and the normal temperature is regained within the next 
twenty-four hours, or somewhat more slowly. The symptoms at defer- 
vescence by lysis will be presently described ; they are usually severe, as 
seen at late stages of ' continued ' fever proper. 

Amongst the less known symptoms belonging to the late epidemic 
in Bombay was the occasional occurrence of a scanty but distinct erup- 
tion of pink spots, supervening usually at the close of the attack, and 
seated on the chest, abdomen and arms. The spots are small, and 
either quickly subside, or, darkening in hue, they present a staining of 
the skin with hceraatin, or they become distinctly hsemorrhagic and 
petechial, and then last for a week or ten days ; successive crops may 
be noticed for two or three days, but not longer, and their outbreak may 
be deferred to the relapse. This eruption was not associated always 
with one type of the fever ; it is not peculiar. 

In general it might be said that two classes of cases were intermingled 
during the epidemic; one, namely, displaying a comparatively sthenic type, 
but, to judge from descriptions, never equal to the European standard 
in robustness ; and another evincing rather an approach to typhus fever. 

The preceding description applies to a well-defined series of phe- 
nomena beginning in health and ending in convalescence, and com- 
prising, it may be, the entire attack of illness. There is no apparent 
difference in origin, symptoms, intensity, and duration between the 
single manifestation and the first of a recurrent series ; and when death 



42 SPIRILLUM FEVER. 

supervenes it generally takes place in connection with this invasion 
period. 

As to the forecast of a recurrence of the attack, I am unable to 
mention any conditions which would assist in this. From presumably 
the same source of infection, both a single and a recurrent attack may 
arise in different individuals {e.g. as happened in two servants attached 
to the fever ward of the G. T. Hospital) ; yet I have noticed that when 
a patient undergoes a second infection after a long interval, the form of 
fever will be the same on each occasion, and also that affected members 
of the same family will often show attacks of a similar form. 

Supposing, as happened in about three-fourths of all patients surviving, 
that a 'recurrence,' or the so-called 'relapse,' takes place, I proceed 
briefly to describe the order of events ; and it may be understood that 
one description appUes to the first few days after the invasion-attack, 
whether the fever reappears or not. 

J^irsf Apyretic Interval. — In the great majority of ordinary cases, 
which are also the milder, the predominant feature of this period is 
debility. This state unquestionably results from the previous febrile 
excitement, but there is not such a close correspondence between the 
two conditions as might, upon general grounds, be anticipated ; and it 
is a remarkable feature of the spirillum fever that reaction and convales- 
cence should often be so prompt and so early. Although he had been 
suffering from high fever for a week, yet the patient, if tolerably robust, 
may revert to his normal condition almost or quite as quickly as if he 
had undergone simply an attack of ague ; it is true he will have lost 
more flesh, but with the crisis the disease has been as emphatically dis- 
carded. This is not the case with some other specific pyrexias of high 
intensity and brief duration. 

Temperature and Pulse. — Commonly after the first day or two follow- 
ing the crisis, there commences a gradual rise of body heat to the normal 
level, which is attained just before the onset of the relapse, or somewhat 
earlier. Even when no recurrence takes place, the temperature is 
restored in the same gradual manner ; and sometimes I have then noted 
at about the eighth day, a slight and brief perturbation (corresponding to 
a latent relapse) prior to the temperature becoming fixedly normal. 

The pulse, on the other hand, not at the crisis wholly subsiding, 
gradually descends to the normal frequency, or below this, by about the 
eighth day ; and there then may occur either a slight rise, as of tempera- 
ture, with no further sign in the abortive cases, or a great and sudden 
rise, which appertains to the true relapse. 

The usual daily ranges of pulse and temperature are, as a rule, main- 
tained throughout; hence this non-spirillar interval is a quasi-normal state. 

A remarkable variation, however, occurs which happened as often as 
one in six of all cases, could not be foretold, and commonly was not 
indicative of serious consequences. I refer to a sudden rise of tempera- 
ture supervening promptly after the crisis, and sometimes so pronounced 
as to simulate a return of the attack. This event occurs equally often 
after the second attack (first relapse), and I have been accustomed 
to term it the 'rebound,' or 'secondary' fever. Its duration is brief, 
and the blood spirillum is invariably absent. The general symptoms 



CLINICAL SUMMARY. 43 

are those of fever, but less marked and peculiar than in the specific 
attack. 

Other symptoms. — The following have been noted in marked cases : 
Headache or heaviness, much thirst, aches, moist skin, and much- 
debility for a time; a tendency to dryness of the tongue and a brownish 
fur with florid sides and tip ; the bowels still costive, but appetite 
speedily regained, and sometimes good or even voracious at the beginning 
of this stage. 

Sleeplessness is apt to continue, and in even mild cases slight delirium 
was not uncommon, now sometimes first appearing ; and this last remark 
is true of jaundice. Diarrhoea and vomiting have been seen just after 
the crisis. Tenderness and enlargement of the liver speedily subside, 
ceasing altogether in a few days. Splenic implication also promptly 
diminishes, but the size of this organ is usually not so soon reduced, 
and prior to the relapse it may again become enlarged. Pink spots 
were sometimes first seen a day or two after the crisis, passing into true 
petechial marks when associated with persistent typhus symptoms. 
Cough (mild bronchitis) is a symptom that may now first appear, or 
become more troublesome. 

In a few days the headache and thirst quite subside ; the aching pains 
of the back and limbs (chiefly the lower, and much increased on exer- 
tion) may persist, and be the cause of much distress. There are tem- 
porary sweats, not said to be preceded by feverishness. The stools are 
bilious, and often unusually so ; deafness and neuralgia. The condition 
of the urine was not found to be abnormal in the great majority of cases ; 
once in twenty it contained on the second day a little albumen : mean 
specific gravity, 1015 ; this was temporary, and renal casts were never 
present ; generally the urine is rather copious, pale, and of low density. 
(Edema of the feet (without albuminuria) is sometimes noted in the first 
part of this interval. 

In most hospital patients convalescence was gradual, in even the 
milder cases ; muscular and cardiac debiUty lasted longest, with deep- 
seated aches ; jaundice and cough but slowly subsided. Emaciation 
was sometimes pronounced, even after a single attack. Anaemia was 
not a usual sequela, nor were pre-existing local affections notably in- 
creased by the fever. Irregular aguish attacks seemed to be occasionally 
re-excited. These points will be discussed hereafter, with complications 
likely to arise at this stage. 

When a relapse supervenes, this apyretic stage comes to its end in 
about seven days. 

Second Attack: First ^Recurrences or '■Relapse.'' — This is a brief 
and variable repetition of the first attack ; and though for the time pro- 
nounced, its general severity, and still more that of succeeding relapses, 
is decidedly reduced. 

As compared with the invasion, in fully developed first relapses the 
maximum temperature, particularly towards the close of the attack, is 
somewhat higher, and the pulse almost equally exceeds in frequency ; 
the common symptoms, generally speaking, are less marked, but they are 
characterised by greater debility. Much, however, depends upon the 
intensity of the relapse, which, contrary to the tolerably fixed character 



44 SPIRILLUM FEVER. 

of the invasion, is a very uncertain datum, — there being seen every grade 
of febrile disturbance from a sUght rise of heat to a continuous paroxysm, 
ahuost equal to the first. 

That the second attack is a curtailed copy of the first, is shown by 
its frequent resemblances as displayed in the temperature chart, with 
respect to deviations in course and general character, which were some- 
times even faithfully reproduced ; and there are no clinical features in 
the replica, which can be termed strictly new. It will, therefore, be 
sufificient to allude to the modifications of symptoms presented. 

Prodromata. — It is well worthy of notice that the relapse not rarely 
sets in quite abruptly, and without any precedent symptoms apparent to 
ordinary observation. On many occasions the patient has expressed 
himself as continuing to improve, or even better than usual, until within 
a very few hours of the attack. As frequently, however, there was some 
headache or pains in the body, or there were distinct chills, indicating a 
preliminary paroxysm. Some more unusual signs will be mentioned 
below. The attack usually supervenes after noon, sometimes in the 
night, rarely in the morning. 

Pyrexia, — As contrasted with the invasion, here the initial rise of 
temperature is not quite so abrupt and high (mean of first day, io2°F.) ; 
but before long the body-heat may attain a higher elevation than it had 
in the first attack, and a similar exacerbation may take place just before 
the crisis ; there being often a depression of mean temperature before or 
at the middle of the attack, which may proceed so far as to become a 
cleft in the chart. The pulse seems commonly to attain its maximum 
(mean ii8 per minute) more slowly and gradually. In all cases there 
occurs the usual morning decline and evening elevation of temperature, 
the mean daily range being greater than in the invasion, but only occa- 
sionally exceeding 2°F. ; and the pulse oscillates similarly, but somewhat 
less in proportion. 

In selected cases under analysis, the pyrexia continued in the mean 
for about five days ; never exceeding seven, and being generally briefer. 

The crisis is equally abrupt as at first, being accomplished in a few 
hours, or slowly prolonged at the end ; the mean fall was 7°'5, the maxi- 
mum 11° -8, the absolute lowest temperature noted being 94° "8 ; the 
normal line of 98° -5 F. was always reached, but very seldom did the fall 
cease there. Generally the crisis occurs during the night or early 
morning. 

A brief ' rebound ' not unusually now takes place, immediately after 
the crisis ; the patient then rallies, and the second apyretic interval 
begins, which much oftener than not passes into permanent con- 
valescence. 

Other symptoms.— The initiatory chills of the first day may reappear 
on the second, indicating an exacerbation of the fever, which is not un- 
common during the earlier part of the relapse. Perhaps the most pro- 
minent symptom is marked headache, most severe about the second 
day, and again after the middle, but less so towards the end. Thirst, 
often urgent, and early complained of, increases throughout. Dryness 
of the fauces was noted, and the tongue becomes rapidly coated with a 
white creamy covering, which afterwards turns to brownish ; it is moist 
at first, and sometimes dryish and roughened at the close, the edge and 



CLINICAL SUMMARY. 45 

tip acquiring a florid hue and its volume shrinking. The skin remains 
dry, except during decided remissions, and when the critical fall is at 
hand ; it sometimes becomes pungently hot and harsh. Sleeplessness 
is a common symptom at the height of the attack, and some delirium at 
night may appear with or after a remission towards the close, but it is 
not common. Aching pains, generally distributed, increase in severity 
from first to last, and are very seldom absent ; they are much complained 
of, and are referred to the back, loins, larger jomts and lower limbs, 
including both muscles and joints, and exacerbating with the pyrexia. 
The abdominal fulness, tension and tenderness, chiefly in the upper 
zone, may appear early but are most marked towards the end of the 
attack ; and the same is the case with splenic enlargement, which, al- 
though more frequent than at the invasion, is not always so considerable 
as to be detected without special care. The liver is less often enlarged, 
though even early there may be decided tenderness (elicited in move- 
ment or pressure), which also augments with the fever ; jaundice was 
rare, but a third of the prolonged cases showed it at last. Bilious vomit- 
ing, on the other hand, was rather commoner at first, and with the mid- 
exacerbation ; it may be attended with hiccup ; nausea is an entry at the 
time of final exacerbation. The appetite for solid food was commonly 
impaired, yet there were curious exceptions. Deafness is an entry co- 
incident with midway delirium, and also epistaxis. 

The urine is commonly plentiful and of density rather below the 
mean, until near the close of the attack, or with a mid-fall ; it was 
usually acid in reaction, and when examined, always in this series free of 
albumen or organised sediment. The bowels were costive, especially at 
first ; the stools were always bilious ; diarrhoea might supervene. 

In general the symptoms are modified by daily changes, and by less 
regular movements of pyrexia, which may lead to a pseudo-crisis in the 
midst of the attack ; a tendency existing to remit, or even towards in- 
termission, not observed in the first attack. 

The blood-spirillum is always present, and may abound ; it precedes 
the beginning of the relapse, and disappears immediately before its 
close. 

Seco7id Non-Febrile Interval. — This stage in the interrupted se- 
quences of the spirillum fever, becomes defined only in the event of a 
third attack, or second recurrence or ' relapse,' which was seldom seen 
in hospital practice. 

But even when no distinct relapse occurs, sometimes a perturbation 
of bodily heat about the fifth or six day appears ; there being at the same 
time some signs of constitutional disturbance. 

When the relapse takes place, this second interval commonly proves 
longer than the first, its mean duration being ten days. Rallying after 
the crisis of the preceding relapse is usually prompt, and unattended by 
the rebound ; the temperature and the pulse speedily regain the normal; 
the general symptoms are mild, and chiefly point to debility ; headache 
seldom persists after the first day, but aching pains in the loins and 
lower limbs, back and upper limbs, are common, and may last for a 
time ; the tongue is dryish, and brown only at first, and in attacks of 
a low type ; the skin supple, and the state of the bowels varies, yet 



46 SPIRILLUM FEVER. 

constipation is not obstinate ; nausea and vomiting are rare, and the 
appetite soon returns. The spleen subsides, and so hepatic signs ; but 
jaundice may persist, and even now for the first time appear. The dehrium 
of the second febrile stage seldom extends to this interval (one in eight 
cases), then being limited to the night-time, and declining in a day or 
two ; the patient sleeps. Cough may last, or now first come on, as was 
noted of the first apyretic interval. Commonly the patient continues to 
improve until the very day, perhaps hour, of succeeding relapse. When 
there happens a decided complication — feverishness, diarrhoea, or bron- 
chitis will interrupt this level course ; but they were rare in the ordi- 
nary cases under review. 

Second Relapse. — A third attack of the genuine spirillar type is not 
commonly seen, though some quasi-periodic febrile disturbance is apt 
to succeed the first relapse ; and the aid of the microscope may be 
needed to ascertain its real character. 

Second recurrences differ from the earlier attacks by their briefer 
duration and less regular form ; they last from two to four or five days, 
and when shortest may consist of a single prolonged paroxysm extending 
little over twenty-four hours ; if lasting longer, the pyrexia may be sus- 
tained, but its tendency is to remit or intermit, and I have seen an 
entire day's interval of low temperature intervene (the spirillum being 
present) between the two or three paroxysms of ague form, which consti- 
tuted this second relapse ; so marked an interruption was never seen in 
prior attacks. Owing to such liability of variation, no satisfactory mean 
type can be elicited ; of temperature and pulse some data are given 
below. Other symptoms are as follows : commencing abruptly morning 
or evening, chills or even rigors are not uncommon (which is noteworthy 
in connection with the intermitting tendency), and in milder degree 
these may be repeated with succeeding febrile accessions. Headache, 
thirst, severe aching pains, burning of the eyeballs or sockets, burning 
of the soles, have been noticed at beginning and end ; the tongue is 
coated, and usually remains moist, but with continuous and low fever 
it speedily becomes dry and brownish ; the liver is seldom implicated, 
the spleen oftener from the second day onward, at least one-half my 
cases showing a large and tender spleen on the fourth day ; the appetite 
is suspended, and thirst may be considerable ; the skin is frequently 
moist in association with remissions and intermissions of the fever ; the 
bowels may be costive or free ; diarrhoea has been noted at the end. 
Jaundice reappears here, as during the earlier recurrences, but delirium 
is unusual, it occurs at the fall ; bilious vomiting may be present in 
connection with the febrile exacerbations. Some critical perturbation 
is noticed in prolonged cases, and the fall is marked by sweats, pains, 
and great debility. Throughout, weakness is a prominent feature, 
yet there is no character peculiar to this stage, which is at most a mild 
repetition of the preceding febrile attacks ; in general, the symptoms 
vary more at morning and evening, according to hours of remission and 
exacerbation ; the blood-spirilla may abound. 

Third Interval. — As applies to non-febrile periods previously named, 
this apyretic period becomes defined only when terminated by a dis- 
tinct pyrexial recurrence, here called the third relapse or fourth attack, 



CLINICAL SUMMARY. 47 

reckoning from the first. Since hospital patients would seldom stay 
long enough under observation, opportunities of seeing this period 
throughout were not numerous : its duration was ten to fourteen days. 

Commonly the state immediately succeeding to the second relapse is a 
quasi-normal one, and offers no distinguishing characters, whether or not 
a third recurrence takes place ; only when this does occur, there are 
somewhat oftener signs of perturbation {e.g. a rise or fall of body heat) 
about midway of its course. Depression persisting after the last crisis, 
the body heat may remain subnormal for a few days longer, with a pulse 
rallying more slowly than the temperature. 

The general symptoms are those of a depressed state gradually over- 
come ; thus, the tongue cleans, and appetite and sleep return ; a glazed 
tongue has been seen to persist ; the pains subside gradually, and head- 
ache is uncommon ; the pulse improves, and the abdominal viscera 
resume their normal condition. Variations here refer to a sub-latent 
febrile perturbation occasionally noted about the middle of this period, 
and manifested by headache, pains, giddiness, feverishness at evening or 
sweats at night, chills being rare ; the spleen may become enlarged and 
tender ; depression attends. Other signs were a burning sensation in 
the soles of the feet, sleeplessness, an irritable tongue, all lasting for a 
few hours only, but leaving an unfavourable impression on the system ; 
actual pyrexia may be overlooked. Then follows a return to the state 
of quasi-health, which continues until the day of relapse. 

Third Relapse. — Considering that a third recurrence or fourth attack 
of spirillum fever, supervenes only after a month or more subsequent to 
the invasion, it will be readily understood that it was seldom seen 
amongst hospital patients, and may therefore be commoner than appears 
from the records. There were six instances entered of this event, but 
most cases were not seen throughout, and some reliance had to be 
placed upon the history as given by the patient. These late recurrences 
occurred mostly during the height of the epidemic and in young sub- 
jects; they were not necessarily preceded by severe attacks, and in them- 
selves were mild, varied and brief, being seldom regarded as more than 
ephemeral events, entailing only some moderate perturbations of health. 

I have hardly a doubt that in the more pronounced of them the 
blood-spirillum reappears, and might be found upon special scrutiny ; 
but it happens that no opportunity occurred of applying such special 
tests, as the Albrecht method and staining process. 

Duration of attack one to four days, wholly or in part. 

The pyrexia commonly assumes the form of a single paroxysm more 
or less prolonged ; at the longest remitting, yet still acuminated ; and 
the temperature may reach 103° to 104° ; when briefer, the rise may be 
little above the normal ; the fall is comparatively slight, but was clearly 
indicated in even the mildest cases. The pulse rarely rises much above 
100 per minute, and its decline is gradual. Other symptoms recorded 
are headache always, pains in the lower limbs, coated tongue, loss of 
appetite, constipation, vomiting at onset (not rare), jaundice, splenic 
uneasiness, though not hepatic ; brief recurring feverishness without 
chills or sweats, thirst, sleeplessness, undoubted depression of the sys- 
tem, and considerable perspiration at the end. The relief that follows, 



48 SPIRILLUM FEVER. 

is more decided than might be anticipated from the seemingly mild cha- 
racter of the attack. I may add that the fever-free state which ensues, 
has been clearly characterised by a subnormal temperature lasting for 
several days, liable to be marked by occasional brief depressions, and 
only gradually rising to the normal level ; the instances are too few for 
further comment. 

Fourth Relapse, and Subsequent Recurrences. — There was available 
in the whole series of relapses seen, only one clear instance of fourth 
recurrence or fifth febrile attack. It occurred in a youth who in hos ■ 
pital had a well-marked first relapse (invasion attack prior to admission), 
which was followed by others mild in character and successively briefer, 
though rather more pronounced, the fifth event being represented by a 
prominent single paroxysm rising abruptly at evening and culminating 
the following morning at 104° ; the crisis followed in the evening of the 
second day, and next morning (third day) the temperature was 9 7° '4, 
which is rather low for these later series. In this case, the apyretic inter- 
vals were level and not extremely long; the patient was discharged five 
days after the last attack, and nothing further was known of his illness. 

Of Fifth relapses I have no definite information to offer. 

Amongst the few cases of relapsing fever unusually detained in 
hospital, there might be seen minor derangements of temperature and 
health which showed a periodic tendency ; and in some general features 
a resemblance to the brief and abortive attacks regarded as standing in 
place of first, second, or third relapses. Such detained cases were very 
few in comparison with those early discharged ; and it is reasonable to 
suppose that some of the latter would have displayed similar marked 
perturbations. Cases were also sometimes admitted for debility or 
diarrhoea, with a history of late recurrent fever, and showing soon after 
entry two or three isolated paroxysms, which appeared at intervals fairly 
corresponding to those of known late relapses, and were open to inter- 
pretation as fifth or sixth recurrences. Little attention could commonly 
be given to these brief events, and ordinary microscopic observation 
commonly failed to detect the blood-parasite. Upon two or three 
occasions, however, the simpler search was successful during such iso- 
lated, ague-like attacks, and thus their character as late specific relapses 
became clear ; that they were not due to fresh contagion in hospital, I 
inferred from the fact of no primary attack of spirillum fever in man, 
ever presenting the form of a dissociated or single daily paroxysm. 

General Features and Variations of Relapsi7ig Fever. — Severity 
of the disease. — Cases are mild or severe according to the intensity of 
pyrexia, and the presence or absence of local complications ; the in- 
fluence of personal destitution and starvation was not very apparent, but 
it could seldom be accurately gauged ; and unquestionably the majority 
of patients brought to hospital in dying state, bore the signs of extreme 
indigence. During the febrile stages pyrexia is often excessively high, 
surpassing the range in other continued fevers ; yet this consideration 
becomes of less importance in spirillum fever than in typhus, since 
usually the attacks do not last long enough to thoroughly exhaust the 
sufferer or induce permanent local lesion ; and the same remark applies 
to comparison with severe remittents. A liability to complications always 



CLINICAL SUMMARY. 49 

exists. Notwithstanding its pronounced character, this fever is decidedly 
less fatal than the others just named ; and this feature appears to be due 
not only to the mild character of the infection, but also to the relief 
afforded by the apyretic intervals, during which the patient approaches 
more or less towards convalescence. Were the whole series of two or 
three febrile periods to be accumulated into a continuous pyrexial state, 
I doubt not the death-rate of relapsing fever would at once be raised. 
The extremes of age add to risk. 

Many casualties take place in connection with the first attack, from 
high fever and its immediate attendants ; others at subsequent early 
date and a few later on, from local complications. I did not learn that 
pre-existing organic disease is necessarily aggravated, or that a tendency 
to chronic lesions is often set up by the spirillar infection. 

General Cou7'se. — Why some attacks of fever should be single (in a 
practical sense) and others composite, remains unknown : when mul- 
tiple, the successive events are dissociated except as regards the ensuing 
feebler state of the patient. The disease is severest at first, and it abates 
by abbreviation and deferring of the pyrexial recurrences : thus, the 
attacks which were at first continuous, next assume the remitting and 
finally the intermittent type. The liability to acute complications also 
diininishes in order of time. Whilst in general apyretic intervals present 
the aspect of a quasi-convalescence, yet they are truly incubation-periods 
of successive illnesses. 

Duration. — Regarding an infected state of the body and the disease 
as one and the same, the following averages are met with : — Duration of 
an abortive attack of spirillum fever 14 days, of which 7 febrile : the 
ordinary attack with one relapse lasts 26 days, of which 12 febrile : 
the rarer attack with two relapses lasts 39 days, of which 15 febrile. 
Pre-febrile or incubation periods last 7, 7 and 10 days, in all 24 : the 
successive febrile manifestations occupy 7, 5 and 3 days, in all 15. By 
common reckoning, the first incubation-period or that of the invasion 
attack, is not included in the duration of illness ; yet it is as much a part 
of it as the succeeding pre-febrile stages, which are not so liable to 
be overlooked. The data on which these statements are founded will be 
furnished in the following Chapter IV. ; considerable deviations are met 
with. 

Stages. — The correct way of viewing the succession of febrile and 
non-febrile phenomena which compose the stages of an ordinary illness, 
would be to regard them not as parts of an indivisible whole, but rather 
as repetitions (varying in number) of similar clinical elements. An entire 
attack of spirillum fever may consist of one incubation-stage and one 
febrile manifestation, a considerable number of cases practically showing 
no more. The first incubative period is usually disregarded, and only 
the culminating pyrexia attracts attention : in recurrences the period of 
latent infection is known as the apyretic interval, and looked on as a 
stage of the disease, though mostly void of symptoms. As variations 
the apyretic period may be lengthened (perhaps by the suppression of a 
relapse) or shortened ; or it may be occupied in part or whole by 
secondary or superadded febrile phenomena, such as a rebound or fever 
symptomatic of local lesion, and so may become almost obliterated. 
There is reason to suppose that both malarious and ordinary continued 



50 SPIRILLUM FEVER. 

fevers sometimes co-exist with spirillum fever, and under ordinary in- 
spection they equally obscure its peculiar features ; but I have invariably 
found that the true interval is preserved, inasmuch as then the blood- 
parasite disappears (whatever the temperature), to reappear in due course. 

The pyrexial stage itself may, after the first attack, be abbreviated in 
every degree : it is never lengthened, except in the very rare cases where 
a redoubled relapse may be suspected. Even in the midst of febrile 
complications it may with due care be recognised at the appropriate time, 
through means of its attendant spirillar blood-infection : naturally it 
tends to become shorter in the relapses, and in any one of them may be 
so much abbreviated as to be practically non-existent. 

The type of the fever has been alluded to as regards the first and 
succeeding attacks. Only general terms apply here, for after much 
labour spent in comparing and analysing the ordinary temperature charts 
of the several periodic events, I have arrived at the conclusion that the 
spirillum fever is more variable in its course than any of the other so- 
called continued fevers, and almost as variable as the malarious. The 
first attack is probaby never intermittent ; the second may be so when 
the series is about to be closed : I have occasionally seen a tendency to 
repetition of type in the whole series of three attacks, but no rule obtains 
after the first onset. The change of type at successive febrile manifes- 
tations, accords with their progressive abbreviation and mitigation in 
degree ; and when the order from continued to intermittent is checked 
or reversed, the indication is one of increasing severity : this is an ex- 
tremely rare event. 

The height of the fever ordinarily bears a relation to its duration, 
thus the pyrexia is most pronounced, as a whole, at the invasion : it 
may, however, for a brief period be equally or more elevated in a first 
recurrence ; if high subsequently, its duration is still more limited : com- 
monly it is not nearly so marked. 

Form of Fever. — Practically there are two forms of spirillum fever, 
namely the abortive and the relapsing ; or, preferably, the single and 
the repeated. Of recurrences the number varies considerably; and as in 
successive attacks the type of fever becomes modified, it may be said 
that this disease merits the distinction of being elevated into a genus^ as 
much as does malarious fever; having equally a specific cause, and many 
modifications worthy to be ranked as species. 

In a strict sense, the spirillar infection probably always reproduces 
itself once, at least, in the body ; but not always in a palpable manner : 
when febrile disturbance is excited thereby, the manifestation is apt to 
vary exceedingly ; it being understood that the last pyrexial attack is 
always less pronounced than the one precedmg. The difference, there- 
fore, between single and repeated attacks is, that in the former there is no 
evident recurrence ; whilst in the latter the repetitions, one or more, are 
sufficiently marked to attract attention. 

Co7nplications. — These occasional attendants upon the disease may 

be regarded as either belonging to the febrile stages, or as incidental to 

them ; probably none being absolutely peculiar. The state of the 

patient previous to infection is an important item in determining their 

^^^-r'J3jC<!lJtrence, and it was commonly one of debility amongst my hospital 

APR 21 192! 



ILLUSTRATIVE CASES. gt 

patients ; the other leading condition relates to the amount or quality 
of infection, and nothing is known of this except by its effects. Com- 
plications belonging to the fever, may be said to be concerned with the 
blood or the blood-vessels : of the former little that is definite could 
be learnt with the microscope alone, excepting as regards the blood- 
parasite and cell contents, though I feel sure there are other ascertain- 
able conditions of the circulating medium, which would prove of the 
highest interest : of the latter, there were noted congestions, thrombi, 
embolisms and infarcts, with resulting hsemorrhages, sloughing and 
inflammation in different parts of the body. Visceral complications are 
also of a general character, and occur in all three cavities of the trunii ; 
the more vascular organs probably suffering most, or oftenest. Com- 
monly, however, the attack leaves no permanent lesion. 

Sequelce. — There are none special known, and but few were witnessed: 
the conditions of observation were not however very favourable. 

The above account is in effect an amplification of the Definition first 
submitted, as regards the clinical history of spirillum fever. Each of 
the items named will next be discussed in detail, with separate chapters 
on Mortality, Diagnosis, and Prognosis. Under the heading of Pathology 
the outward conditions and essential nature of the disease will be treated 
of The blood-parasite is described separately. 

ILLUSTRATIVE CASES. 
Single Febrile Attack. 

Case VIII. — M., 25, servant in a fever-ward, G. T. Hospital. First day — 
while on duty seized suddenly with fever and chills at 2 p.m., has frontal headache, 
pains in loins, no marked splenic or hepatic uneasiness, slight cough ; t. 104°, p. 140 : 
a few spirilla in the blood. Second day — m. t. 102'', p. H2, much headache, no 
thirst, hepatic and epigastric tenderness, lumbar pains, one stool ; e. t. 103° "6, 
p. 120, splenic enlargement and tenderness, pains in limbs : spirilla very few. Third 
day — m. t. 103° -4, p. 130, resp. 44, has the typical aspect, no sweats, much head- 
ache, slight thirst, tongue white, moist, slight cough, and sputa scanty, abdomen teader 
and not distended, sev re body-pains and cannot sit up ; two watery, bilious stools ; 
vomiting last night ; spirilla few : e. t. I03°'2, p. 134, persistence of symptoms. 
Fourth day — m. t. 103°, p. 130, resp. 36, no sweats, much thirst, pains severe and 
a sense of distension in the joints of limbs ; other symptoms persist ; he is oppressed 
and sinks in his bed : e. t. 102° •4, p. 152, resp. 40 : three stools ; no sleep : spirilla 
several. Fifth day — m. t. 103'', p. 130, resp. 30: the symptoms persist : vomiting last 
night; he slept from chloral given; skin now moist; three stooL : e. t. 103° '8, 
p. 136, resp. 44 : no worse : spirilla several. Sixth day — m. t. 102° '2, p. 130, r. 40 : 
cough increased, sputa frothy, no dullness or pain of chest, spleen no more enlarged : 
e. t. I02°'2, p. 126, r. 32: no change : spirilla many. Seventh day— crisis— 5.30 
A.M., t. 99°, p. 94, r. 32 : perspiiing freely, slight headache, slight thirst, cough and 
abdominal uneasiness diminished : vomiting in night and he slept a little (chloral re- 
peated) : 8 A.M.; t. 94°'6; 4 P.M., t. 95^'6, p. 100, feeble, r. 34, skin clammy. 
Eighth day — m. t. 96°, p. 92, r. 32 : depression continues, pains in joints, tenderness 
in lower part of abdomen, one stool ; he eats : e. t. 97°, p. 96. Ninth day — m. t. 
97°"8, p.86, pains increased, no abdominal tenderness : e. t. 98^*4, p.90. Conva- 
lescence progressed slowly on account of the arthritic pains, but seemed uninter- 
nipted : on the fourteenth day the m. t. was 100°, p. 108, and the signs of pyrexia 
slightly increased ; next day similar and slight chills ; .again on the following day, 
when some abdominal tenderness reappeared ; after this, return to normal temp. : 
the blood was examined twice daily from 12th to 17th days inclusive, and without 
clear positive results, fully-formed spirilla, at least, not being seen ; possibly they 
were overlooked. Pains in the shoulders and some epigastric tenderness persisted 

E 2 



52 SPIRILLUM FEVER. 

for a fortnight ; the man was much reduced in flesh. His fellow-servant was attacked 
the day before him and suffered more, undergoing a marked relapse ; and so another 
attendant in the same ward. 

Fever with One Relapse. 

Case IX. — F., set. 35. Hindu from the Deccan famine-districts, one month in 
Bombay ; resides in a large house with many countrymen and relatives from the same 
village, several of whom have been admitted into this hospital with spirillum fever. 
A small, thin subject, at reputed eighth day of illness. A.M. temp. I04°'2, pulse 132 : 
frontal headache and pains of joints, slight thirst, hepatic and splenic enlargement and 
tenderness: tongue coated, but moist, p.m. t. 105°, p. 136 full and soft, respirations 
44 : skin moist ; marked tenderness in upper abdominal zone, spleen 2^ inches below 
cost, cart., liver not enlarged upwards but downwards 2 inches, epigastrium not dis- 
tur'^ ed, but tender ; abdomen moderately full ; no tenderness elsewhere : bowels 
open to-day. Heart's sounds clear, the second being accentuated, even at apex. Some 
bronchial rales heard in the chest ; her breathing is hurried and general aspect dis- 
tressed. The blood is full of spirilla. 

Ninth day of disease. — A.M. t. 104° -8, p. 148. P.M. t. I04°'4, p. T40, resp. 44. 
Fever slightly less, the acme being passed ; no sweating yet ; hypochondriac and epi- 
gastric tenderness less, abdominal fulness the same ; has appetite and some thirst, 
but dislikes cold water as likely to bring on chills ; temporal headache only on 
coughing ; pains in the elbows and knees, without swelling. Heart's sounds weak, 
but clear ; an impulse is perceptible which extends to the xyphoid cartilage and 
even to the right side of it ; second sound accentuated at the base. The liver and 
spleen are but slightly reduced in size. The night's urine was 13 ozs high-coloured, 
quite clear, sp. gr. loio, acid, albumen |, chlorides doubtful (on the addition of 
nitrate of silver the colour becomes deep purple and there is cloudiness, but no 
deposit on standing for two days) : urea, 61 '2 grs. : the day's urine 16 ozs., very high- 
coloured, clear, sp. gr. 10 10, albumen none, chlorides doubtful (colour changes to 
yellow-brown as above), urea 70-4 grs. The blood full of spirilla. 

Tejith day. — Crisis. A.M. t. 97° "2, p. 90, resp. 26. Subsidence of fever with 
copious sweats at 3° a.m.: the distress is gone ; no collapse, though she cannot stand 
from pains in knees and weakness : liver and spleen much less tender and pro- 
jecting ; epigastric tenderness also less : some thirst ; skin n"w dry (7 a.m.) : trou- 
blesome cough since the fall began. Night's urine, 35 ozs., high-coloured, clouded 
but without sediment, reaction acid, sp. gr. 1006, albumen a decided trace, chlorides 
undetermined ; urea 123-2 grs. 4 P.M. t. 96°, p. 78, resp. 26; 6 P.M. t. 96° -6, p. 72 ; 
had sweats during the day, headache quite subsided, pains in knees and ankles con- 
tinue ; spleen felt i^ in. below the cost. cart, but not tender ; some tenderness on 
firm pressure over epigastrium, and more over lower edge of liver which reaches to 
I in. below the cost. cart, in nipple line. No exhaustion : heart's systole fairly 
heard (no murmur) though the pulse is decidedly feeble and small. Day's urine 
22 ozs., rather high-coloured, clear, sp. gr. loio, acid, albumen none, chlorides none, 
bile-pigment much, urea 96-8 grs. 

Eleventh day. — a.m. t. 96°-4, p. 80, resp. 28, P.M. t. 96°-6, p. 84, resp. 34. 
Looks much pulled down, but is not exhausted ; troublesome cough at night ; addi- 
tional pains in shoulders and elbows; no swelling. Night's urine 11 ozs., high- 
coloured, clouded, no sediment, sp. gr. 1015, chlorides ^g' ""^^^ iii"3 grs.: day's 
urine 13 ozs., very pale, rather clouded, no sediment, sp. gr. 1003, acid, chlorides 
-i- (no tint on addition of nitrate of silver), urea 30-3 grs. 

Twelfth day. — a.m. t. 96° -4, p. 78, resp. 28, rallies very slowly, pulse is weaker 
and first sound of heart less distinct : skin dry ; pains in upper limbs more, preventing 
sleep : no swelling of the stiff and bent shoulders and elbows ; extension increases 
the pain : she is crippled by pains in the lower limbs, which are referred to the 
upper margin of the patella and insertion of the ligamentum patellae, and are much 
increased upon exertion. Appetite good, but still some epigastric tenderness ; volume 
of liver and spleen much reduced, and tenderness less; abdomen flattened. P.M. 
t. 98''"2, p. 80, resp. 30 : chief complaint is pain and stiffness of the right shoulder 
(the deltoid muscle being stiff and tense) and elbow, so that she cannot move these 
joints ; the hands are quite free; the knees are bent and stiff, and she cannot stand 



ILLUSTRATIVE CASES. 53" 

without assistance. Urine : night, 30 ozs., rather high-coloured and clouded, no 
sediment, sp. gr. 1006, chlorides i, urea I58'4 grs. : day, 12 ozs., pale, clear, sp. gr. 
1006, chlorides ^, urea about 30 grs. 

Thirteenth daj/.—T. 97°'6, p. 70, resp. 26. Cough less, pains in r. shoulder 
and the knees also diminished, and she can now walk a little and raise the arm ; no 
wasting visible : the appetite has now become voracious. Spleen not to be felt below 
the cost, cart., it is probably measurable but the parts are now very lax and the 
organ very mobile : liver has resumed its normal dimensions ; some epigastric 
tenderness remains, no pain after eating, no vomiting. Pulse has improved, and heart's 
first sound is better heard ; it is of rathing booming character over mid-cardiac 
region. P.M. t. 98°"4, p. 72, resp. 26, the pains are less than in the morning. Urine : 
night, 40 ozs., pale and tolerably clear, sp. gr. 1004, acid, chlorides | : day, 12 07s., 
pale, clear, 1006, chlorid s ^ ; total urea 102-9 g'^s. 

Fotirteettth day. — A.M. t. 97° '6, p. 64, resp. 26. Some cough again, pains no 
worse, still some epigastric tenderness on firm pressure but no tumefaction ; pulse is 
very feeble, though the heart's impulse is perceptible, p.m. t. 98°, p. 64. Urine : 
night, 18 ozs., pale, clear, 1006, chlorides \ : day, 16 ozs., pale, acid, 1004, chlo- 
rides \ : combmed urines, urea, 89*7 grs. 

Fifteenth day. — Sixth day of apyretic interval, and two days before the relapse ; 
A.M. t. 97° "4, p. 60, resp. 22 : cough at night ; pains in r. shoulder and knees felt 
only when she moves about. Epigastric tenderness less ; spleen just felt under the 
lowest ribs, not tender ; heart's action firmer, impulse and first sound distinct, second 
sound accentuated at base only ; pulse moderately firm. P.M. t. 98°, p. 60, resp. 24. 
Urine : night, 24 ozs., pale, clear, 1004, chlorides | : day, 22 ozs., pale, tolerably 
clear, no sediment, sp. gr. 1005, acid, chlorides \, urea in mixed urines 85 "i grs. 
Microscopic examinations of blood — first specimen taken at 9 A. M : the appearances 
indicate the presence of spirillum : tri-hourly records now begun of temperature, 
pulse and state of skin and blood. 

Sixteenth day. — Day before beginning of the relapse ; A.M. t 98°, p. 60, resp. 
22. No pain in the shoulder, and in the knees only at rising ; still slight tenderness 
of epigastrium on firm pressure ; cough less ; slept : spleen can be felt and its an- 
terior border is probably a little tender : appetite good. P.M. t. 98° -4, p. 58 (the 
minimum velocity) and small ; resp. 24 : she moves about the ward free of pain, no 
increased thirst ; heart's sounds feeble, the second pronounced and impulse not felt ; 
liver and epigastrium unchanged, spleen barely felt and the uneasiness which is ex- 
perienced on pressure seems to be over the costal cartilages at their junction with 
the 7th and 8th ribs, and not over the spleen itself ; no headache, no pains. Weight 
of body 76 lbs. Uiine : night, 36 ozs., pale, clear, acid, 1008, chlorides ^ : day, 
18 ozs., acid, 1006, chlorides i, mixed urines, urea 76 grs. Blood examinations : 
the spirilla are distinct and not very few in some specimens taken. 

Seventeenth day. — First day of relapse. A.M. t. 99^*4, p. 70, resp. 24 ; skin dry, 
no headache, no thirst, no loss of appetite, no giddiness, no pains in the joints or 
limbs ; no tenderness in epigastrium or hepatic region (no enlargement there) or in 
the left hypochondrium, though the spleen is somewhat increased in volume since 
yesterday and is felt I in. beloiv the 9th and loth costal cartilages : second sound of 
the heart pi'onounced, the first is attended with an indistinct murmur over the mid- 
cardiac region, at apex of sternum and to the right side, but not upwards. There is no 
distress, but she lies down and is timid. Night's urine 24 ozs., pale, clear, no sedi- 
ment, sp. gr. 1008, acid, albumen none, chlorides |, urea 73 '9 grs. P.M. t. 105° -6, 
p. 108, rather full, very soft, resp. 40 : skin of forehead and chest moist, that of 
limbs dry : she had chills at 12.30 noon (t. already over 102°) and some sweats 
(limited as above) at 4.30 p.m. ; now (5.15) skin again drying : no pains in limbs ; 
spleen certainly not larger than in the morning (perhaps a little smaller), not at all 
tender ; no hepatic enlargement or tenderness, but the localised spot at apex of ster- 
num still tender on pressure : cardiac impulse less forcible and the first sound barely 
heard anywhere, no murmur in recumbent posture, but a cooing sound at once heard 
in sitting posture, impulse then very faint. Thirst a little more, appetite not im- 
paired and has eaten pulse and rice ; looks a little harassed ; no giddiness on stand- 
ing and no pains in loins : has drunk only about 8 ozs. of water and yet urine 
abundant: a little cough. Urine of day ; 42 ozs., pale, clear, acid, 1006, albumen 
none, chlorides^, urea ioo'3 grs. Rather more spirilla in blood. 



54 SPIRILLUM FEVER. 

Eighteenth. — Second day of recurrent fever : A.M. t. 103° -2, p. 108, rather firmer 
and less fuP, resp. 36. Skin soft : temple headache ; much thirst at night, less now ; 
no pains in limbs ; some tenderness in epigastrium, not over liver and spleen ; oc- 
casional cough ; appetite fair. Tongue pale, little coated, moist, large ; has drunk 
water freely. Hear'^^'s action feeble, a soft murmur heard in mid-cardiac region only 
(? in muscular substance) not prolonged, second cardiac sound pronounced at apex and 
base; r. side of heart over-disiended (?) : cough bronchitic. Spleen decidedly enlarged, 
but not nearly so much so as at close of invasion-attack, moveable and quite free 
from tenderness on even firm pressure ; liver not enlarged downward and reaching 
hardly so far as costal margin, not at all tender, so far as accessible to pressure : the 
epigastric tenderness is rather more marked (?), no fulness but some tension of 
parietes here ; no pain, flatus, or eructation ; no nausea or vomiting after food ; no 
jaundice : some tenderness at edge of ribs themselves on left side, as noted before. 
I found the skin dry, shrivelled, an hour later and the patient with a pale, harassed 
look ; sleeps ; wants meat. Urine of night : 38 ozs., rather pale and clouded, no 
sediment, acid, loio, no albumen, chlorides \, urea 127 grs. 4 P.M. t. io6°'4, 
p. 124, less full and soft; resp. 46: skin dry: temple headache; shooting pains in 
calves when she attempts to walk, not in joints ; no giddiness ; more thirst but drinks 
little ; no appetite, a bitter taste in mouth after eating ; no vomiting ; tenderness in 
umbilical and epigastric regions ; she sweated twice in the day, namely at noon and 
3 P.M. : no delirium. Spleen projects considerably, slightly tender; liver proportion- 
ately less enlarged and not tender ; umbilical uneasiness on pressure may be nervous, 
rest of abdomen free. H. 's second sound more pronounced, impulse feeble and 
murmur inaudible in recumbent posture ; some distress of countenance ; slight bron- 
chitis. Urine of day : 22 ozs., high-coloured, very clear, no sediment, sp. gr. lOiO, 
acid, albumen none, ch'orides ^-^ (urine again becomes dark brown colour and very 
turbid on addition of nitrate of silver solution, hence the deposit, also tinted, may 
not be all chlorides), urea 86 -8 grs. Blood — spirilla many and sometimes clustered. 

Nineteenth. — Third day of relapse. A.M. t. 105° -8, p. 136, soft, small and feeble ; 
resp. 42 : -skin dry ; tongue pale, shrunk, slightly coated and dryish : has diffused 
headache ; thirst (drank only 8 ozs. of water in night) : giddiness when walking ; no 
pains of arms, but shooting pains in calves and knees when moving : no vomiting ; 
no appetite ; griping about the navel ; some tenderness over hepatic, splenic and 
umbilical regions, and much over the epigastrium ; bowels freely moved once this 
morning, stcol said to be semi-consistent ; gastric uneasiness after eating : slight 
cough occasionally, no sputa. My notes add— distress, pallor, weakness, eyes yel- 
lowish ; herrt's action feeble, second sound pronounced, no murmur, no impulse 
seen : abdomen retracted rather than full ; spleen more projecting, yet hardly tender ; 
liver not more projecting and not tender ; epigastrium not distended, yet tender ; 
umbilical tormina at brief intervals and some tenderness on pressure ; vomited some 
bile when cleaning her mouth with her fingers (in native fashion), complains of 'pit' 
(biliousness) : the hands and feet feel cold, whilst the trunk feels very warm (a ther- 
mometer held in the fist stood at 102° -6) : some moisture of skin in the early morning; 
now dryness and shrinking of integument. Urine of night, 20 ozs., high-coloured, 
cloudy, no sediment, acid, loio, no albumen, chlorides | (dark purplish-brown tint 
as before) ; urea 88 grs. Great numbers of spirilla in blood. 

4 P.M. t. 106^ -2, p. 136, resp. 44; skin moist, had sweats at i p.m., and again 
now, about the head, trunk and upper extremities ; much frontal and temporal head- 
ache ; nausea, but no vomiting ; no giddiness ; pains in knees and calves on move- 
ment only ; three stools, semi-consistent ; no griping, but tenderness in epigastrium ; 
hepatic tenderness, not splenic ; little appetite, everything except water and meat 
causing a bitter taste ; feels as if the belly were puffed, whereas it is neither distended 
nor flaccid : has thirst but is unwilling to rise to drink, has taken only 4 ozs. of 
water with meal ; tongue pale, dryish, but almost clean and not shrunken : the 
patient looks haggard, thin and distressed ; no delirium, no dreams ; cough not 
increased. Upon measurement the left lobe of the liver was found to be more 
enlarged and tender ; whilst the spleen had not increased in volume. Urine of day : 
II ozs. only, high-coloured, rather cloudy, no sediment, sp. gr. 1012, acid, no 
albumen, chlorides g (colour as before) ; urea 65 '3 grs. Much bile-pigment. Temp, 
of hand io4°"6. Blood— many spirilla, but seemingly fewer with this exacerbation. 
20th day of disease, ^th of this relapse.— A.u. t. 104° -8, p. 126, very small and 



ILLUSTRATIVE CASES. 55 

feeble, respiration 42. Skin dry : tongue pale, little coated, not shrunken, dryish ; 
slept with the chloral : has much frontal and temple headache, no giddiness yet can- 
not walk from muscular debility and trepidation ; heart's action feeble, no mur- 
mur or impulse, second sound all over pronounced. Spontaneous vomiting last 
night, contents of stomach ejected, no blood ; nausea preceded vomiting; no histoiy 
of fever-crisis there. Two stools: feculent and yellow : no griping ; hepatic, umbilical 
and especially epigastric tenderness considerable, no splenic tenderness though t e 
viscus is laiger than yesterday ; liver rather larger and particularly the left lobe ; no 
abdominal distension, but some rigidity over epigastrium due to muscular tension 
and, possibly, to presence of left hepatic lobe ; no right iliac gurgling. (Memo, on 
the case. — The gastric and duodenal tenderness are here marked, the latter being 
felt on deep pressure only ; the ileum and colon being more superficially placed, 
would be more readily reached). Pains in calves and knees on movement ; no 
appetite and aversion to meat food which she craved for two days since ; much 
thirst but dare not drmk water freely (8 ozs. taken) lest the belly should become 
more distended : eyes yellowish, pupils dilated ; facies less harassed (she had slept 
last night) ; no delirium : more cough, bronchitic. sputa copious, fine frothy, no dull- 
ness of chest anywhere. Urine of night : 16 ozs., high-coloured, clouded, no sedi- 
ment, sp. gr. loio, acid, no albumen, chlorides ^^ (deep purple, clouded hue) ; urea 
105-6 grs. Temp, of hand said to be 98° only, or 6° -8 less than the axillary. 
Blood — spirilla many. 

4 P.M. t. l05°-6, p. 138, resp. 40 ; skin dry; tongue coated and dry; no 
headache or vomiting ; much thirst ; one pale, scanty yet feculent stool ; hepatic 
and epigastric uneasiness, not umbilical ; pains in calves and knees as before ; no . 
giddiness ; has appetite, but food distasteful and in spite of thirst she refrains from 
drinking cold water, lest it should cause chills and toothache. There was slight 
sweating at i P.M. on the upper part of the body. Being very low, 2 ozs. of rum 
were administered which induced some rallying : spleen very tense, yet only a little 
tender on firm pressure, liver less full, abdomen more retracted. Urine of day : 14 
ozs., high-coloured, cloudy, acid, 1012, albumen j^, chlorides not certain (a dark 
grey, scanty deposit, from the dark green, opaque solution, on addition of nitrate 
of silver), urea 102-8 grs. : a scanty sediment furnishing no definite stractures. 

2,1 st, fifth and last day of relapse. — T. 105°, p. 132, f eble, running ; resp. 34 : 
skin dry, lips pale, tongue tends to dryness, a little coated ; some sweats at i A.M.; 
slept well (chloral), no dreams ; much thirst, drank luke-warm water about 15 ozs. 
in the night ; no headache, or giddiness or vomiting ; no stool ; pain on pressure 
over hepatic, epigastric, and inner half of splenic regions ; abdomen not retracted, 
visceral enlargement not more and spleen rather less tense ; left lobe of liver, 
over the stomach, is tender. - Pains in knees and calves, and also in shoulders and 
elbows, so that cannot lift right arm without help of the other. No appetite. 
Heart's action seems more excited, yet feebler ; second sound pronounced, first sound 
attended with a murmur in mid-cardiac region only : both sounds heard at apex of 
sternum and to the right of it ; murmur not more distinct there. 

There is a scanty eruption of small, pink, raised spots on the left arm ; some 
seem not quite recent, others may be of earlier date. There is no sign of the typhoid 
state, but rather pallor and weakness. 

Urine of night : 12 ozs., very high-coloured (reddish), clear, no sediment ; acid, 
sp. gr. 1013, albumen doubtful (cloudiness only), chlorides doubtful (a scanty deposit 
in the dark green solution), urea 88-1 grs. Microscopic examination, negative 
results. 

Blood — many spirilla, and some large, nucleated cells. 

3 P.M. Severe rigors coming on, t. 108° -6, p. 150 ; very copious sweating 
followed half-an-hour after the chills ; frontal and occipital headache came on with 
the rigor and she was much agitated, not recognising ' day and darkness : ' t. became 
dry and it is stated that the spleen at the same time was more swollen and tender. 
This was doubtless a genuine perturbatio critica. 

4 P.M. t. 104° -2, p. 150, resp. 40 : skin dry, no giddiness or vomiting; no stool, 
abdomen full ; pains of limbs the same ; hepatic, epigastric and splenic tenderness 
remain ; also thirst, has drunk 8 ozs. of water. 

6 P.M. The excitement has passed away, skin dry and hot (an hour later i03''-2), 
heart's action moderated, p. 128 (an hour after 1x6), soft, first sound free from 



56 SPIRILLUM FEVER. 

murmur ; spleen larger and still tender, epigastrium very tender and the liver also to 
some extent, but there is little change here since morning : the woman has acute 
pain shooting from the front to the back of the head, body aches, but she is not more 
distressed or depressed than earlier in the day : no signs of the crisis yet. 

Urine of the day i6 ozs., very high-coloured, clouded, no sediment, acid, 1013, 
albumen a trace ?, chlorides not known (colour changed to light brown with cloudi- 
ness only), urea 124*6 grs. Blood, 4 P.M — The spirillum has disappeared since 
I P.M., when the numbers were already declining : many large, nucleated cells are 
present. 

7.2nd day, end of 7-elapse by critical fall. — A.M. t. 96° "6, p. 84, feeble, resp. 28; 
skin now dry ; tongue coated, dryish ; slight diffused headache ; some pain on move- 
ment in right shoulder and elbow ; knees and calves still painful on movement : 
hepatic, epigastric (especially) and <;plenic tenderness : no appetite : thirstless, drank 
about 4 ozs. of tepid water in the night ; cough troublesome in the night, sputum 
scanty, frothy ; slept fairly (no chloral), and probably wandered a little, being 
under the impression of being beaten : no active delirium : no stool for two days. 
Her face is pale and pinched ; no collapse, yet she cannot stand from weakness and 
pains in lower limbs ; heart's action much feebler, no impulse felt and even the 
second sound is faint. Spleen is one inch less than yesterday, yet still prominent 
and a litile tender ; liver less and not tender ; epigastrium not distended and still 
tender : the abdomen is moderately full : jauu' iced aspect less. The main descent 
of temperature amounted to 8°, and the reduction of pulse-rate to 66, as shown in 
the chart ; there were no sweats in the night, but only some moistness of the skin 
at I A.M. (report). 

Urine of night : 12 ozs., very pale, clear, no sediment, sp. gr. 1003, acid, al- 
bumen none, chlorides none ? (on addition of nitrate of silver solution a deep brown 
tint, but no cloudiness on standing) ; urea 23 '7 grs. 

Blood— no trace of the parasite : a few large pale cells, 

4 P.M. t. 97°, p. 82, small and feeble; resp. 28; skin moist; tongue pale, 
coated, dryish ; no headache ; is deaf in both ears since morning ; no giddiness ; 
pupils dilated ; no vomiting ; pains of r. arm and lower limbs less, abdomen 
somewhat distended ; still some hepatic and sp'enic tenderness, and more epigastric ; 
one stool of natural amount and consistence, very pale hue ; slept in the middle of 
the day ; free sweats at 2 p.m., and again at 4 : no thirst ; cough the same. 
Dreamt in her sleep, but is not delirious ; she is too weak to stand and can only sit 
up. On being weighed in a similar dress this evening, it was found that she had 
lost 10 lbs. avoird. since the i6th day, or more than ^ of body- weight during this 
relapse not yet quite finished, her present weight being 66 lbs. Urine of day 19 
ozs., high-coloured, clouded, no sediment, acid, 1013, no albumen (or cloudiness 
only), chlorides f (colour of mixture light brown but clear and the deposit of 
chloride of silver large and well defined), bile-pigment much; urea I56'3 grs. ; 
the aspect of the urme had become febrile again, a great contrast to its morning 
state ; the woman had drunk only 4 ozs. of water during the day. 

ly^d, secojid day of critical fall. — a.m. t. 96°, p. 80 feeble, resp. 24 : skin diy, 
tongue pale, moist, coated in middle ; slept well, dreamt once ; there were copious 
and general sweats at lo p.m. (t. sank to 95°'8, vide chart), and twice afterwards ; 
one stool scanty, natural, contained a lumbricus ; appetite good and eats heartily : 
deafness still, and sense of heaviness in the head, no giddiness, pupils contracted, 
conjunctivae still yellowish ; some tenderness remains in the upper abdominal zone, 
particularly in epigastrium ; the spleen is now 2 in. beyond the costal cartilages in- 
stead of 4 in. and not so hard as before; has still pains in knees and calves, less 
so in the arm : cough not increased. Heart's sounds very faint, even the second. 
She drank 10 ozs. of tepid water in the night. Urine of night 15 ozs., very high- 
coloured, clear, acid, 1013, albumen none, chlorides ^. 

4 p.m. t. 97°"6, p. 86, resp. 26: skin moist, tongue pale, repeated perspi- 
rations in the day, i- slowly rallying, being able to move off the bed : complains most 
of pains in the lower limbs and weakness : the deafness remains and some local 
abdominal tendcness ; the spleen has gone down | in. since morning : had hiccup 
and gaping, Ijefore and after taking food ; no pain after eating, or nausea, but only 
some over-fulness of the stomach felt : a natural stool, probably containing some of 
the urine. Urine of day 11 ozs., high-coloured, quite clear, chlorides 5 : total urea 
of mixed urines 226*5 grs. 



ILLUSTRATIVE CASES. 57 

2i^th day, prolonged crisis.— A.M. t. 96°-4, p. 74, resp. 24, skin dry, tongue 
coated, increased c ugh at night preventing sleep ; free sweating at 10 p.m., has 
temple headache, no giddiness, left ear still deaf, hiccup and one stool in the 
night, abdominal uneasiness subsiding, still some epigastric tenderness not fulness 
or tension ; spleen at f in. and softer ; liver nearly normal. Heari 's soimds clear 
and stronger, the second still much predominating : stool solid and yellow, eyes still 
tinged ; she can now walk a few yards and has gained i lb. in weight (67 lbs. body 
weight). 

Urine of night 20 ozs. (probably some passed with stool), pale, clear, no sedi- 
ment, sp. gr. 1006, acid, albumen none, chlorides |-, urea 63-3 grs. : this rever- 
sion to the character of urine at main crisis was concurrent with a slight decline of 
temperature last night. P.M. t. 98°, p. 80, resp. 26, skin dry : no sweating ; pains 
in r. shoulder and knees the same, no pain in the calves ; some epigastric tenderness ; 
the spleen is now at the edge of the thorax : she is hungry yet has no taste for food, 
is languid and indisposed for exertion ; the rallying is slow and intermittent. 

Unne of day 14 ozs., high-colour d, clouded, sediment?, acid, 1012, albumen 
none, chlorides near ^ (colour pale and precipitate defined) : urea 887 grs. 

25M. A.M. t. 96° -6, p. 68, feeble, resp. 22, skin dry, tongue coated at root, slept 
well, sweating in the night on head and trunk, thirst none, yet she has drunk 15 ozs. 
of water, there being a slight rise of t. at 10 P.M., no headache, pains in knees less, 
cough less, still epigastric tenderness, one natural stool ; second sound of the heart 
pronounced, yet feeble. She is very weak and pallid, yet not giddy, and can walk 
with help. Urine of day 44 ozs., pale, clear, 1006, acid, chlorides ^. 

P.M. t. 98° '2, p. 76, resp. 24, no sweats, knees still painful and stomach rather 
tender. Urine of day 20 ozs., pale, clear, 1004, acid, chlorides ^ : total urea of 
mixed urines 197" I grs. 

26//?. A.M. t. 97° "8, p. 70, better volume, resp. 24, tongue clean, no sweats in 
night, no deafness, some pains in r. knee when walking, cough this morning ; 
heart's sounds distinct, the first now heard, but second predominating ; spleen reduced 
so as to impart only a sensation of fulness and resistance in left hypochondrium : 
liver normal : some epigastric tenderness remains : appetite improving but she does 
not drink as much as in health : weight of body 67 lbs., or not more than that of 
two days ago. Urine of night 34 ozs., pale, clear, 1006, acid, chlorides -g. 

4 P.M. t. 98° "8, p. 76, resp. 24 : drank 8 or 10 ozs. of water, appetite fair. 

Urine of day 18 ozs., pale, clear, ioo5, acid, chlorides ^ : urea of mixed urines 
130-4 grs. 

2'jt/i. A.M. t. 97° '4, p. 70, resp. 22, some cough this morning, some sweats at 
night, no pains in knees, still epigastric tenderness ; appetite good, not voracious ; 
stools brown and consistent. 

Urine of night 28 ozs., pale, clear, 1008, acid, chlorides A, urea 1047 grs. 

P.M. t. 98° -8, p. 74, resp. 24, skin moist, still epigastric uneasiness. 

Urine of day 36 ozs., pale, clear, 1004, acid, chlorides Jg, urea 507 grs. 

28tA. A.M. t. 97° '8, p. 62, resp. 22, no fresh symptoms. Urine of night 39 ozs., 
pale, clouded, 1008, acid, chlorides ^. 

P.M. t. 98*^ -8, p. 68, resp. 24, still some epigastric uneasiness on firm pressure. 

Urine of day 33 ozs., very pale, clear, 1004, neutral, chlorides ^^ ; combined urea 
1837 grs. 

29//;. A.M. t. 97° '4, p. 76, slight sweats in night ; urine of night 49 ozs., pale, 
clouded, and ammoniacal from early decomposition (microscopic examination showed 
no abnormal particles), 1007, albumen none, chlorides ig. 

P.M. 98°'4, p. 68, re-p. 24 ; still slight epigastric tenderness. Urine of day 
31 ozs., pale, clear, 1007, chlorides ^, urea of mixed urines I58"4 grs. 

30M. A.M. t. 98° -4, p. 60, still feeble and small, resp. 22 ; improvement gradual, 
the spleen is barely to be felt on manipulation upon turning the patient on her r. 
side. 

Urine of night 29 ozs., acid, 1007, chlorides ^. 

P.M. t. 98^-8, p. 64, resp. 24, no splenic uneasiness and hardly any epigastric. 

Urine of day 34 ozs., pale, clear, 1006, acid, chlorides ^, mixed urea iiO"8 grs. 

Blood — contains no abnormal ingredient. 

^isL A.M. t. 98, p. 62, resp. 22, no headache or pains, no spleen, or liver, change, 
stools natural ; no signs of relapse. Pulse at 4 A.M. only 58 ; sp. gr. of urine risen. 
Weight of body 68 lbs., a gain of 2 lbs. only since the fall. 



58 SPIRILLUM FEVER. 

Urine of night 44 ozs., pale, clear, sp. gr. loio, acid, no albumen, chlorides i. 

P.M. t. 98° -8, p. 60, resp. 22, spleen distinctly felt when patient turns on right 
side, not tender : no other sign of relapse. Urine of day 52 ozs., pale, clear, 1003, 
neutral, chlorides j-:, mixed ureas 1 57 "6 grs. 

^27id. A.M. t. 97°, p. 60, resp. 22 ; the spleen is the same, not tender. Urine of 
night 33 ozs., pale, tolerably clear, acid, lOiO, chlorides |. 

4 P.M. t. 98°"4, p. 56, resp. 24; free .sweating at 3.30 p.m., no epigastric un- 
easiness. 

Urine of day 39 ozs., pale, clear, 1004, slightly acid, chlorides ^, combined 
ureas 183 "7 grs. 

33rc^. A.M. t. 98° '6, p. 54, resp. 20, spleen just perceptible, not tender, no pains 
anywhere. 

Urine of night 47 ozs., pale, clear, acid, 1006, chlorides g. 

P. M. t. 98 "6, p. 56, resp. 22, no complaint. 

Urine of day 37 ozs., clear, pale, acid, 1008, chlorides i, urea of mixed urines 
166-3 grs. 

34//z. A.M. t. 97° '8, p. 54, resp. 24, no abnormal symptoms. 

Urine of night 51 ozs., clear, pale, acid, 1006, chlorides ^t. Second relapse 
indicated. 

P.M. t. 99° "2, p. 58, resp. 24, skin dry; tongue clean, the spleen is not changed. 

Urine of day 40 ozs., pale, clear, 1006, acid reaction, chlorides ~q, mixed . 
urea 228-2 grs. 

35/A. A.M. t. 98° "2, p. 56, resp. 24, free sweating in the night, no discomfort of 
any kind, did not drink more liquid than usual (36 ozs.) Body weight 74 lbs., a 
gain of 6 lbs. Urine of night 66 ozs., pale, clear, neutral reaction, 1004, chlo- 
rides j^. 

P. M. t. 99° -6, p. 60, resp. 24, spleen unaffected. 

Urine of day 21 ozs., very pale, clear, acid, 1005, chlorides ^|, combined urea 
153-1 grs. 

^6t/i, A.M. t. 98° -6, p. 62, resp. 2j, some sweats in the night, spleen not en- 
larged. 

Urine of night 47 ozs., very pale, clear, acid, 1003, chlorides i, urea 82 -3, grs. 

P.M. t. 100°, p. 66, resp. 26, some sweating at 3.30 p.m., no headache, tongue 
coated at the root ; spleen not enlarged downwards. 

Urine of day 36 ozs., pale, clear, acid, 1008, chlorides ^^, urea 60-1 grs. 

37^/2. A.M. t. 99°, p. 54, resp. 24, some sweating at midnight, complains of aching 
in the back on both sides the spine, spleen unchanged. 

Urine of night 52 ozs., pale, rather clouded, 1004, neutral, chlorides y\. 

P.M. t. 1 00'^ -2, p. 68, resp. 26, looks a little pulled down and weak, yet body 
weight 79 lbs. , and therefore still gains, no enlargement of spleen. 

Urine of day 35 ozs., pale, clear, acid, 1008, chlorides |, urea of combined 
urines 172-2 grs. 

2,8ik. A.M. t. 100° -4, p. 72, resp. 26, slept well, no headache, thirst, giddiness, 
or pains in limbs, the aching in the back felt only in the neck now, slight epigastric 
tenderness only, the spleen is distinctly enlarged and firm. She is feverish at day- 
time as well as night. 

Urine of night 50 ozs., pale, clear, acid, 1006, chlorides ^5- 

P.M. t. 103° -6, p. 88, resp. 32, skin dry, tongue moist, coated at the back, some 
headache, had chills at i P.M., pains in elbows on moving, no giddiness, or thirst ; 
still some epigastric uneasiness only, spleen enlarged ^ inch downwards, not tender, 
appetite good. 

Urine of day 27 ozs., pale, clear, acid, 1006, chlorides j~, urea in united urines 
172*2 grs. 

Blood — examined each of the last three days without decisive results, but it is 
possible that immature spirilla were present during this mild second relapse. 

39M. A.M. t. 98°, p. 72, resp. 24, general perspiration in the night (except 
soles of feet) , and great relief with decline of temperature, spleen still felt, no ab- 
dominal uneasiness. 

Urine of night 42 ozs., pale, clea'-, acid, 1006, chlorides Jg. 
P.M. t. 99° -2, p. 80, resp. 28, skin dry. 



ILLUSTRATIVE CASES. 59 

Urine of day 30 ozs. , normal aspect, acid, 1006, albumen none, chlorides ^-^a, 
combined urea I77'4 g'S- 

i\olIi. A.M. t. 98^-2, p. 64, resp. 24, no general or local uneasiness. Urine of night 
44 ozs., pale, clear, acid, 1006, chlorides ^^g, urea 129*7 grs. 

P.M. t. 98° "6, p. 66, resp. 22, skin dry. 

^\si. A.M. t. 98°, p. 64, resp. 22, no abnormal symptoms. P.M. t. 98° "8, p. 64. 

42W. A.M. t. 98° -4, p. 68, improving. P.M. t. 99° '4, p. 70. 

^yd. A.M. t. 98° -4, p. 66, body weight 84 lbs. P.M. t. -98° '8, p. 66. 

44//? day of disease. A.M. t. 97° "8, p. 64, discharged at her own request; con- 
valescent in aspect. 

The concurrent data of First Relapse in this case are furnished in a separate 
Chart 3, in Section III., Chapter I., 'On the State of the Blood in Spirillum Fever.' 

Another example is furnished in Chart 2, Plate IV. at the end. 

Fever with Two Relapses. 

Case X. — II. A., jet. 36, male, Mussulman, petty shop-keeper, six months in 
Bombay, resident in a well-known fever locality; home Azimghur (N. India); ad- 
mitted May 27, 1878, with fever of seven days duration. Morn. 1. 103°, p. no, soft ; 
a heavy distressed look, pupils coniracted, mind perplexed; tongue much coated, 
white at sides, dry and brownish in centre, with narrow fluid edges and tip ; lips 
parched : slight jaundice, frontal headache, pains in loins and lower limbs (bones), no 
pains in hands : liver unchanged, spleen distinctly enlarged, not tender : skin soft, 
moist ; no appetite. Heart's sounds clear, the first not prolonged, but rather short- 
ened and weakened, even when the man sits up and the impulse so rendered percep- 
tible. The fever is said to be contii uous and more severe of late ; has had a dry 
cough for tive or six days. He is a spare, pallid, feeble subject : intelligent. 

Blood-plasma clouded, but fibrillation distinct : little free protoplasm : red discs 
piled ; very numerous active spirilla, commonly in rings. Ordered aiaphoretics and 
stimulants. 

Vesp. t. 104° "4, p. 120, undulating : liver, spleen and epigastrium full or enlarged, 
and tender; bowels said to be regular; much thirst, can eat ; skin drj, no eruption ; 
no iliac gurgling. 

30th. 7 A.M. t. I03°"6, p. 124, full, but soft; no stool; tongue dryish: was 
slightly delirious last night, jaundice more marked, skin dry ; there was some 
sweating in forehead at 8 p.m. : severe headache and pains in back and limbs ; much 
thirst : urine said to be passed frequently in small quantities, high-coloured, sp. gr. 
lOlo, acid : shows only a few granules under microscope. No eruption : pupils 
small : lips dry : systolic sound of heart faint : some bronchilic cough. Splenic 
dullness in axillary line measures 5 inches, from lower border of 8th rib to i inch 
below costal margin, and reaches to 3 inches from the median line : hepatic dullness 
from lower border of 5th rib to 1;^ inch below costal margin, in nipple line. 

Vesp. 4 P.M. t. i04'^-2, p. 120, full, but soft : tongue dry in middle ; jaundice 
deeper ; skin dry, no sweats during the day : one semi-solid stool of yellowish-green 
colour : aspect anxious, countenance dusky ; the man wanders in speech ; pupils 
rather contracted. N.B. Acme of Invasion-attack about this time. 

31st. A.M. t. 99 '"2, p. 100, smaller, soft ; hepatic dullness now from upper 
border of 6th rib to costal margin, being therefore reduced : splenic dullness from 
lower border of 8th rib to I inch below costal margin, and 3^ from the median 
line, being also reduced, but less so ; the fulness and tenderness over hepatic, 
splenic and epigastric regions is less marked : one liquid, yellowish-green stool : 
tongue still dryish, and lips. No sleep in the night, being very restless and wander- 
ing in speech. Conjunctivse less yellow, headache and pains less, thirst continues. 
Began to sweat freely at 6 A.M., skin now sot, forehead now wet ; no eruption, or 
iliac gurgling : heart's systole seems stronger : complains of uneasiness in throat, 
congestion ot pharynx and fauces present. He looks worn and harassed with features 
pinched, and is still delirious, being under the influence of fear : during the night he 
tried to run away : no account of increased fever then : the temp, has fallen 5^, and 
t e sweating seems inconsiderable : no diarrhoea. 

Vesp. t. 99° "6, p. 108, soft, regular : tongue and lips still dryish : skin soft, one 
liquid stool containing blood and mucus: urine scanty, high-coloured, sp. gr. 10:5 (wi.'h 
correction), no albumen, no sugar, chlorides, bile-acids and pigment in small quantity : 



6o SPIRILLUM FEVER. 

there is cough but no sputum or thoracic dullness ; one bilious vomiting of greenish 
liquid : still some pains in head, trunk and limbs ; no eruption ; there was some 
sweating on forehead and chest at noon. Liver-dullness the same, no tenderness : 
spleen reaches only ^ inch below costal margin, still tenderness here and over the 
epigastrium. (N.B. Crisis ended at noon, the temp, having declined to 98^ ; and a 
rebound promptly follows. ) Treatment sustaining. 

June I. A.M. t. ioi°-8, p. 112, full, soft. Hepatic dullness reaches as high as 
upper border of 7th rib, as low as i- inch above the costal margin : spleen reaches 
below only as far as the costal margin. No eruption, tongue moist, clearing ; lips 
dry ; 4 liquid stools, yellowish-green, with much dark blood and mucus : abdomen 
retracted, tender ; straining and griping at stool. Slept for an hour, but was 
restless and wandering at night : headache and pains less : much thirst ; skin soft, 
there was some sweating about midnight. Urine of night 20 ozs., sp. gr. 1022, 
colour high, acid, no albumen, bile-acids and pigment abundant, and chlorides ^ vol. 
{i.e. much increased). No more vomiting ; he looks haggard and pinched, is drowsy, 
pupils natural and act. Sedatives ordered. 

Vesp. t. 1 02° "4, p. 116, full, but soft; hepatic dullness the same, a little ten- 
derness : splenic dullness reaches to upper border of 9th rib, below to costal margin 
and inwards to 3| inches from median line ; still tenderness here. • No eruption : 
tongue cleaning, lips dry ; 3 semi-solid stools, highly bilious, with streaks of blood 
and mucus, strains at stool : slight body-pains continue : skin moist, there being some 
sweating during the day ; thirst considerable : urine lighter-tinted, acid, 1020, no 
albumen, bile-elements and chlorides still plentiful. He has the same haggard aspect, 
eyes sunken, yellow, countenance dusky ; pupils normal. N. B. this secondary fever 
was probably connected with the dysenteric symptoms. Weight 99 lbs. 

June 2. A.M. t. 100° "6, p. 100, full, soft : hepatic dullness the same, still some 
tenderness : splenic dullness reaches from upper border of 9th rib as far as costal 
margin, some tenderness here also : 3 semi-solid, yellowish stools with mucus, but no 
blood, still straining ; jaundice diminishing : tongue moist, lips dry ; face haggard, 
the cheek bones very prominent ; forehead damp, less thirst, still headache and 
general pains : urine at night 24 ozs., acid, 1015, no albumen or sugar, chlorides i 
bile-acids and pigment present. Uvula and phai7nx still injected. Heart's first 
sound still feeble. 

Vesp. t. 100°, p. 102, full, soft ; aching pains in loins and in bones and joints of 
limbs (not the smaller joints), increased on movement. There is redness of soft 
palate and fauces, pain in deglutition limited to pharynx : no sign of paralysis here, 
iDut he swallows liquids slowly and with pain, irritati n of larynx and hawking cough 
following. One scanty feculent stool : still tenesmus. Hepatic and splenic dullness 
the same. Weight 99 lbs. (N. B. The phaiyngitis is a complication here, superven- 
ing with the rebound of temperature shown in the chart.) The man looks very low 
and weak, lips dry, eyes sunken, malar bone prominent ; the sounds of the heart are 
feeble, short and clear, the second much predominating. 

3rd mane. t. 97° '2, p. 92, weak but regular, tongue coated white, with a ten- 
dency to dryness, lips moist, has throbbing headache, the pains in the joints is of a 
gnawing character, thirst less : limit of the liver upwards the upper margin of the 
6th rib, downwards to within | in. of the costal margin, the hepatic region is still 
rather full and tender : limit of the spleen upwards the lower border of 9th rib, down- 
wards 5 in. below the costal margin, still fulness and tenderness here, and also over the 
epigastrium : two stools feculent and bilious, without blood or mucus, and passed with 
a little griping and straining. With this fall there was some sweating at 6° A.M. 
He looks more exhausted, the nose sharp, the cheeks hollow, and has a troublesome 
hawking in the throat ; nothing wrong in the chest, the fauces are still reddened ; he 
slept ; no eruption. First sound of the heart limited to the apex. 

Vesp. t. 98*^, p. 88, still headache and pains : the hepatic dullness reaches to | in. 
from the costal margin, the splenic has the sam- limits as before ; skin moist, con- 
junctivae clearing, no stool, urine free, sp. gr. 1020, chlorides | vol. 

4th mane. t. 98-4°, p. 88, more full, regular ; tongue clean and moist, little thirst, 
the headache and pains in the back much complained of, those in the limbs and joints 
are les^ : liver-dullness from upper margin of 6th rib to about ^ in. from costal margin: 
splenic dullness unchanged : one feculent, bilious stool, passed without griping or 
straining, urine free, slight cough, no sweats, slept well. 



ILLUSTRATIVE CASES. 6 1 

Vesp. t. 98°, p. 80, headache less, no pains in joints, more pain in the back : 
liver and spleen of near normal dimensions, tongue cleaning, the pupillas little pro- 
minent. 

5th. m. t. 97° "8, p. 76, very weak, heart's action very feeble, first sound almost 
inaudible ; much general depression and languor ; the throat is much easier ; skin 
moist, tongue clean and smooth, still pains in the head, back and joints ; liver and 
spleen unaltered, one natural stool. Bark and ammonia, and alcoholic stimulants 
still administered. 

Vesp. t. 98° -4, p. 84, much lumbar pain, less headache, and pains in the knees 
only : no stool : tongue clean ; still a little cough : 2o| ozs. of urine, with chlorides 
Ivol. 

6th. m. t. 98°, p. 80, soft and regular, lumbar pain, some headache and pain in the 
knees, two stools, slight thirst, liver and spleen normal, urine free, tongue clean and 
smooth. 

E. t. 98° -4, p. 84, weak and regular, pains the same, thirst less, no stool, tongue 
clean. N. B. — He was now becoming convalescent, seven days since the crisis of 
first attack. 

7th June. Relapse : m. t. 99''*6, p. 104, full, bounding, soft : thirst, pains in head, 
back and knees are increased, he has a sense of burning in both feet : tongue slightly 
coated, tending to dryness in centre ; pupils normal : conjunctivee yellowish. Fever 
came on at 10 last night, without chills, some sweating three hours later ; skin now 
dry. Urine 32 ozs. at night, acid, loio, clouded, chlorides i vol., no sediment. The 
spleen recedes in the lying posture and is then barely felt ; but when the man turns on 
his r. side, this organ descends 2 in. below the costal margin and is firm, not tender. 
Weight of body 99 lbs., or the same as on the 1st inst., despite the pharyngitis and 
dysenteric diarrhoea : yet no gain, as usually is acquired. Stimulants and support 
continued. 

Vesp. t. 103° -8, p. 120, full, soft, regular; tongue coated dryish, lips dry, skin 
dry, no stool, conjunctivae yellowish, pupils normal ; pain in back severe, much 
headache, also pain in the knees and least so in small joints of hands and feet. Liver- 
dullness upwards to the upper border of 6th rib, downwards to the costal margin. 
Spleen-dullness upwards to upper border of 9th rib, downwards about l|in. below 
costal margin, and inwards 3 ins. from the median line ; there is fulness and tender- 
ness over the entire up;, er abdominal zone. Urine in the day 30 ozs., pale, clear, 
1007, no albumen. Much thirst (drinks water freely) : some pink spots on 1. side 
of abdomen ; the man is oppressed, has a slight cough, throat easier ; there were 
sweats on the forehead about noon : he has good appetite. First sound of the heart 
short, but distinct. Blood-plasma clear, coagulation slow ; a peculiarity is the many 
floating granules in the plasma, active, rounded ; they seem to join together and two 
will sometimes appear connected by an invisible band : there are very few fully 
formed spirilla, intermediate shapes not seen. 

8th. m. t. 102° -4, p. 116, full, soft ; dorsum of tongue smooth and dryish, Hps 
dry, skin dry but not harsh, two consistent bilious stools in the night; jaundice more 
marked ; pupils normal ; much pain in the back, the head, knees, legs, burning 
sensation in the feet : in the upper extremities pain said to be less ; slept ; fever 
exacerbated at midnight without chills, no sweats since, much thirst : liver-dullness 
as yesterday : splenic enlargement increased downwards | in. and inwards j in. ; 
some fulness and tenderness over the entire upper abdominal zone : urine in night 
30 ozs., pale, clouded, no sediment on standing, 1007 ; no erupiion: his face is pinched 
and anxious, skin sallow ; no cough, the throat is less painful : has a hungry crav- 
ing : first sound of the heart rather booming in the lying posture. Blood clear, coagu- 
lation slow, fibrillation distinct, there is free protoplasm of different sizes, a few 
granules and the spirillum rare. 

E. t. 105°, p. 120, bounding, compressible, regular ; tongue coated, moist ; no 
stool : pupils normal, great thirst, pains as before, no eruption ; the liver now 
reaches i in. below the costal margin : the spleen as in the morning : urine 26 ozs., 
acid, 1012, no albumen, chlorides | vol., no sediment. 

9th. m. t. io3°"6, p. 120, full, soft; tongue white and moist at sides and tip, 
smooth and dry in middle, lips dry, one natural stool in the night, eyes yellow, pupils 
normal, much thirst ; much pain in the back, head, knees, burning in the feet, no 
pains in upper limbs, or in throat, no eruption : hunger felt ; liver about | in. smaller 



62 SPIRILLUM FEVER. 

than yesterday ; spleen also slightly reduced : urine high-coloured, cloudy, 1012, 
no albumen or sugar, chlorides | vol., acid, no sediment ; no abdominal uneasiness: 
no sweats, slept, is drowsy and exhausted. Weight 98 lbs. 

Vesp. t. I03°'6, p. 124, full, soft ; no stool in day ; pains as before ; urine 26 ozs., 
acid, 1017, cloudy, high-coloured, no sediment, no albumen, chlorides ^ vol., bile- 
acids and pigment present ; no abdominal uneasiness, slight sweating in the day ; 
liver and spleen of unchanged dimensions. 

loth. m. t. I04°'6, p. 128, full, bounding, compressible; tongue as before, lips 
and skin dry, no sweats during the night, the patient not sleeping well, but being 
restless and somewhat delirious : jaundice marked, much thirst and hunger : two semi- 
consistent yellowish green stools : pains very severe ; throat better ; no eruption : 
urine in the night 28 ozs. , high-coloured, acid, 1015, cloudy, no albumen or sugar, 
bile-acids a trace, bile-pigment present, chlorides | vol. : no abdominal uneasiness. 
Liver limits from upper border of 6th rib to costal margin : spleen from upper border 
of 9th rib to i| in. below costal margin, and 3 ins, from median line : visage anxious 
and dusky. 

Vesp. t. 105° -2, p. 136, full, soft ; tongue glazed and dry in centre, lips parched, 
slight sweats on the forehead at 3 ; he is delirious, muttering to himself and tossing 
about the bed : eyes deep yellow ; much thirst and craves for food ; one bilious 
stool : pains as before ; no eruption : urine of day 29 ozs. , high-coloured, acid, clouded, 
loio, chlorides i vol. Weight of body 97J lbs. 

nth. m. t. 103° "6, p. 120, full, regular, soft; tongue coated, diyish, lips dry, 
slight sweats on forehead at i : no sleep, he being very restless, not so much delirious ; 
two highly bilious stools ; there is a sense of heat in the abdomen, no tenderness or 
fullness, much thirst and hunger : great pain in back, heads, knees and ankles, 
burning in the feet ; no pains in the upper limbs ; no eruption : urine of night 26 ozs., 
pale, clouded, acid, 1015, no albumen, bile-acids and pigment present, chlorides 
i vol. Liver reduced. Spleen extends from the upper border of 9th rib to i^ in. 
below the costal margin, and 3^ in. from the median line. 

Vesp. t. io5°'6, p. 132, bounding, compressible; tongue brown on dorsum, moist, 
lips moist, there has been some sweating on the forehead ; one bilious stool, a sense 
of heat in abdomen, no fulness or tenderness, much thirst and appetite, pains as 
before, no eruption ; he looks very haggard and sallow. Liver-dullness from lower 
border of 6th rib to within i in. of costal margin, where its edge can barely be felt. 
Spleen-dullness from upper border of 9th rib to I5 in. below costal margin, and 3| in. 
from median line. Urine of day 36 ozs., acid, pale, clouded, loio, no albumen, 
chlorides | vol. Weight 96I lbs. 

1 2th. m. t. 10;.° "4, p. 144, full, soft ; tongue coated black except in the smooth 
middle, diy all over ; lips parched and cracked : no sweats in the night ; skin now 
dry ; one highly bilious stool ; sense of abdominal heat is less, no tenderness or ful- 
ness here ; much thirst and hunger ; pains the same with burning in the feet ; no 
pains in upper limbs ; no eruption : his countenance is expressive of exhaustion and 
suffering. Urine of the night 30 ozs. , high-coloured, clouded, no sediment on stand- 
ing, chlorides ~, 1015, acid, no albumen : liver and spleen unchanged. At 3. 30 p.m. 
the t. was 105°, p. 132. 

Vesp. (4) t. 99°, p. 100, small, feeble, tongue dark, moist, lips dry, skin covered 
with sweats now coming out, being preceded by rigors {perhirbatio cridca), eyes 
deeply jaundiced, pains continue, no burning sensation in the belly, no abdominal 
uneasiness, much thirst and hunger, no eruption : urine of day 39 ozs., acid, 1003, 
chlorides -^ vol., no albumen, one bilious stool, liver and spleen unchanged since 
morning. Weight 93? lbs. 

13th. m. t. 99° "2, p. 100, very feeble, regular : tongue brown, moist, lips moist, 
much sweating at midnight for an hour ; skin soft, jaundice still, one stool, there is 
again burning sensation only in the abdomen, much thirst and craving for food, 
vomiting after ingestion ; the pains continue, no eruption ; urine of the night 28 ozs., 
pale, clouded, acid, 1015, chlorides 5^ vol., no albumen: sudamina in the groins, 
pupils rather contracted, abdomen collapsed, the liver reduced and retracted, the 
spleen extends from 7th rib to costal margin, and 3^ ins. from median line. 

Vesp. t. 99° '8, p. 112, very weak, regular; tongue cleaning, moist, lips moist, 
skin soft, two semi-solid stools, thirst less, appetite much, no abdominal uneasiness, 
no eruption ; liver dullness unchanged, splenic-dullness from the 9th rib to | in. 



ILLUSTRATIVE CASES. 63 

below costal margin and 3^ in. from median line. Urine of the day 10 ozs., 
acid, pale, clear, no sediment, 1017, no albumen, chlorides f vol. 8 p.m. skin 
cold, he is very weak and pulse feeble (stimulants and warm clothing), temperature 
not taken. Weight 90^ lbs.' this day. 

14th. m. t. 99^'2, p. 112, feeble (said to be compressed by 150 grammes), tongue 
coated white, moist, no thirst, pains in back, head and limbs the same, no stool, 
conjunctivae less jaundiced, pupils slightly contracted, no abdominal uneasiness, no 
eruption, liver unchanged : spleen of unaltered dimensions : urine of night 28 ozs., 
chlorides ^ vol. Heart's action weak, impulse imperceptible, rhythm regular, 

Vesp. t. 98° -8, p. 108, better volume (200 grammes borne), tongue clean, moist, 
a little thirst, pains less, no stool, conjunctivae anemic, pupils normal, no eruption. 
Liver — in recumbent posture the anterior border does not project below the costal 
margin, but on relaxing the abdominal walls and the patient taking a deep inspiration, 
this edge may be felt on upward pressure, and its notch between the right and left 
lobes can be detected ; dullness in nipple line to upper border of 6th rib, and on deep 
percussion as high as the 4th rib. Spleen— dullness from upper border of 9th rib to 
costal margin and 3f in. from median line. Urine of day 18 ozs., pale, clear, no 
albumen, chlorides ^, acid, 1028. There was slight sweating at 3 P.M., no chills ; 
the t. descended to 97° '2, and this probably represented the end of a crisis delayed 
for some reason. 

15th. m. t. 99°, p. 96, weak, tongue coated, moist, slight thirst, pains in head 
and upper limbs less, but in loins and extending down the legs very severe ; some 
oedema of the feet, conjunctivae pale, pupils normal, no eruption, no stool, no appetite. 
Liver — normal ; spleen extends from upper border of 8th rib to costal margin, and 
4 in. from median line. Urine of night 17 ozs., acid, chlorides |, no albumen, 1017. 

Vesp. t. 97° "6, p. 92, better volume, tongue coated, dryish in centre, no headache, 
pains in loins and legs severe, no thirst, no stool, pupils a little contracted ; liver 
unchanged, spleen the same, no urine since morning (ordered aperient). Body-weight 
89 lbs., being a reduction of 10 lbs in seven days. 

i6th. m. t. 98° -4, p. 100, feeble, tongue clean, some headache and pains in arms, 
much pain in loins and legs, no thii'st, no eruption, one dark-coloured stool, con- 
junctivae pale; liver unchanged, spleen reaches from 9th rib to costal margin and 4 ins. 
from median line. Urine of night 18 ozs., acid, no albumen, high-coloured, cloudy, 
1022, no sediment, chlorides ^ vol., skin soft, slept. 

Vesp. t. 97° '6, p. 96, better volume (350 grammes needed), tongue coated, lum- 
bar and lower limb pains severe, headache and pains in large joints of upper limbs 
slight, conjunctivae pale and yellowish ; no sweats ; is weak and giddy ; liver and 
spleen unchanged; urine of day 6 ozs., acid, pal , clear, 1020, chlorides g^ vol., no 
albumen, bile-acids and pigment present. 

17th. m. t. 97° -6, p. 92, tongue moist, glazed in centre, no sweats, one stool ; 
urine 14 ozs., acid, high-coloured, 1020, no all'Umen, chlorides | vol. 

Vesp. t. 37°"4, p. 92, he is depressed, pupils a little dilated, much lumbar pain, 
no appetite, no stool. 

1 8th. m. t. 98° -6, p. 88, weak, one stool, pains in thighs and legs considerable, 
and prevented sleep; urine 17 ozs., acid, 1017, clear, no albumen, chlorides ^ vol.; 
the spleen is said to extend below the costal margin. E. t. 97° "8, p. 96, no stool • 
he is giddy, pupils a little dilated, the pains continue. 

19th. m. t. 97° '9, p. 80, two stools, pains in legs less, and he can walk a little 
unaided: urine 22 ozs., acid, 1009, chlorides^ vol., no albumen, no bile-acids or 
pigment. 

Vesp. t. 98° -4, p. 82, tongue coated, some sweating about the neck. 

20th. m. t. 98°, p. 75, better strength, two stools, sleep disturbed by the pains, 
appetite improving ; urine 21 ozs., acid, 1009, chlorides | vol. E. t. 98°, p. 72. 

2ist. m. t. 98°, p. 72, one consistent palish stool; urine 24 ozs., acid, 1015, 
chlorides y vol. E. t. 98° -4, p. 72. 

22nd. m. t. 98°'4, p. 72, slow convalescence, appetite capricious, pains less ; 
urine 20 ozs., 1015, acid, chlorides | vol. E. t. 99°, p. 80; improving. 

23rd. m. t. 98°, p. 64. slept, two stools, slight headache (frontal) and pains else- 
where. E. t. 98^-4, p. 76. 

24th. m. t. 98°, p 72, no muscular pains, giddiness, appetite increasing ; urine 
18 ozs., acid, 1012, chlorides g. E. t. 98° -4, p. 96, soft, one stool. 



64 SPIRILLUM FEVER. 

25th. m. t. 98° '4, p. 76, weak, tongue slightly coated, still headache and giddi- 
ness, the muscular pains have returned to-day ; urine pale, 1012, no albumen, chlo- 
rides i. Blood not visibly changed, a few granules are seen but no spirillum in the 
fresh blood. Second relapse. 

2 P.M. t. 103° "8, p. 82, weak (150 grammes), resp. 32 : fever came on an hour 
ago, with chills which are still felt, though less sensibly : skin dry, tongue moist but 
glazed, some thirst, frontal headache and burning sensation in the eyes since mornings, 
pains in limbs the same as before ; the spleen seems unaltered, and the liver is not 
changed, one consistent stool. 

4 P.M. t. 104° •2, p. 92, skin dry, thirst moderate, there is headache and pain in 
the lower limbs. Blood — plasma clear, a few free granules, no spirillum (fresh blood). 
26th. m. t. 101°, p. 96, soft, tongue slightly coated, one stool, no appetite, thirst 
moderate, muscular pains increased, headache and giddiness increased, less sensation 
of cold in the feet, skin moist, conjunctivae sallow ; urine 14 ozs , 1007, pale, no 
albumen, no bile-acids or pigment, chlorides | vol. Blood — plasma clear ; there are 
spirilla few but active, also some short active rods and free moving granules. 

4 P.M. Fever exacerbated with chills at 3, t. I04°'4, p. 100, soft : the pains 
continue the same, burning in the eyes, headache and giddiness ; . the liver and spleen 
do not seem to be changed, no tenderness of abdomen. 

27th. m. t. 103° "4, p. no, weak, tongue coated, moist; no stool; no appetite ; 
burning in the eyes, conjunctivae sallow ; the pains are much increased ; he is de- 
pressed and can hardly answer questions ; liver unchanged, spleen extends from upper 
border of 9th rib to I in. below the costal margin ; no tenderness. Urine pale, 1009, 
no albumen, chlorides | vol. Blood — clear, coagulation slow, much free protoplasm 
large and small, many white cells, no spirillum seen. 

4 P.M. t. 96" "2, p. 76, he is pallid and depressed ; profuse critical sweating since 
I P. M. , headache less, pains in limbs the same ; he is too weak to sit up (ordered 
stimulants). 

28th. t. 98° '2, p. 88, small, one stool, tongue cleaner, headache and the pains 
are less, thirst moderate, appetite improved, skin soft : lungs and liver normal, spleen 
extends from upper border of 9th rib to i in. below the costal margin. Urine 20 ozs., 
pale, 1009, albumen none, chlorides i vol. Blood — clear, coagulation slow, much pro-, 
toplasm, many white cells and free granules, no spirillum seen : the free protoplasmic 
masses are both large and small in size. 

Vesp. t. 96°'2, p. 76, countenance pallid and expressive of exhaustion ; profuse 
sweats since i p.m., skin now bathed in perspiration : headache less: still pains in 
the limbs ; complains of inability from weakness to sit up. 

28th m. t. 98° "2, p. 88, small, soft, one stool in the night, tongue moist and 
cleaning, giddiness, slight headache, the muscular pains much diminished, thirst 
moderate, appetite improved, skin soft ; lungs and liver are normal, spleen extends 
from upper border of 9th rib to about ^ in. below costal margin. Urine acid, 1012, 
albumen and sugar none, chlorides | vol. : 14 ozs. saved. 
Vesp. t. 96° "4, p. 80, no stool, pains the same. 

29th. m. t. 97'^ "3, p. 68, small, weak, one stool in the night, tongue coated, 
appetite increased, thirst moderate, slight headache and sense of burning in the eyes, 
pains in the limbs less, sleeps. Urine 16 ozs., acid, orange-tinted, 1016, no albumen, 
chlorides i vol. Vesp. t. 97 "-5, p. 72. 

30th t. 96° -4, p. 62, bowels regular, slept well. E. t. 97° '2, p. 64. 
July 1st. m. t. 96"^ "2, p. 60, feeble, regular, slight frontal headache, no pains in 
the limbs, the legs feel very weak ; spleen now barely projects beyond the costal 
margin. Urine saved 20 ozs., pale, acid, 1016, no albumen, chlorides ^ vol. E. t. 
97°-2, p. 64. 

2nd. m. t. 97°, p. 60, weak, two stools, natural, tongue moist, cleaner, appetite 
good. Urine saved 15 ozs., sp. gr. 1005, neutral. E. t. 96" -4, p. 68 ; tongue moist, 
slightly glazed, no pains, skin soft, the spleen has receded to the costal margin ; urine 
pale, acid, 1007, albumen none, bile-pigment none, bile-acids present. Weight 
96:^ lbs., so that he has gained 7| lbs. since the first relapse, n twithstanding the in- 
tervention of a brief second recurrence, and this persistent depression of frame. 

3rd. m. t. 96°"5, p. 56, weak, skin soft, giddiness and some headache, tongue 
glazed, moist, appetite good, sleeps well. Urine 26 ozs., 1012, acid, albumen none. 
Vesp. t. 97^'5, p. 68, soft, no stool ; urine 6 ozs., 1016, acid. 



ILLUSTRATIVE CASES. 65 

4th. m. t. 97°, p. 64, one natural stool, only complaint is weakness. Urine 
34 ozs., pale, acid, loio, no albumen, chlorides j vol, E. t. 98^, p. 72, of better 
volume. 

5th. m. t. 97°'5, p. 68, no complaint but weakness, liver and splten seem normal ; 
urine 35 ozs., pale, iOl2, chlorides ^ vol. E. t. 98 ', p. 72. 

6th. m. t. 97° '5, p. 68, better strength, tongue slightly coated, one stool, slight 
giddiness and headache, did not sleep well owing to pains in the 'oins and knees; 
urine 36 ozs., pale, cloudy, faintly acid, 1012, chlorides ^ vol., albumen, bile-acids 
and pigment absent. E. t. 98°-6, p. 80, he feels a little feverish (? la-eral relapse). 

7th. m. t. 97° "4, p. 64, weak, no stool, tongue slightly coated, some headache and 
pains in loins and knees ; liver of normal dimensions ; spleen extends i^ in. below 
the costal margin (i.e. has become enlarged). Urine 36 ozs., neutral, 1014, chlorides ^, 
no albumen. E. t. 98° -6, p. 68. 

8th. m. t. 97° "7, p. 54, small, weak, tongue slightly coated, still some headache 
and pain in the knees : is giddy and too weak to walk ; one stool : appetite good. 
Urine 42 ozs., pale, faintly acid, 1009, no albumen, chlorides ^ vol. E. t. 98°-6, 
p. 74, better volume. 

9th. m. t. 98°, p.. 48, small, one stool, slight pains in lower limbs much increased 
on pressure, headache and giddiness. Urine 40 ozs., pale, lOio, bile-acids and pig- 
ment a trace, chlorides f. E. t. 98° '6, p. 61, soft, fuller. 

loth. m. t. 98°, p. 48, headgche and giddiness on sitting up, lower limbs tremulous 
when extended, pains slight, one stool, tongue coated, breath offensive; urine 37 ozs., 
alkaline from ammonia, readily decomposing, 1015, no albumen, chlorides j vol. 
E. t. normal, p. 64. 

nth. m. t. 98°, p. 70, better strength : the spleen still extends below the costal 
margin ; liver normal. Urine 32 ozs., pale, 1012, chlorides ^ vol. Weight loi lbs.: 
he gains. E. t. 98° -4, p. 72. 

1 2th. m. t. 98° "4, p. 68, sleep disturbed from headache, giddiness and muscular 
pains complained of: the spleen seems to be a little larger again. Urine 36 ozs., pale, 
1013, chlorides j vol. E. t. 98°, p. 86, stronger. 

13th. m. t. 98°*2, p. 68, weak, tongue coated a little; still pains : appetite good ; 
urine 36 ozs., pale, 1012, acid, no a;bumen. E. t. 98°'6, p. 84. 

14th. m. t. 98°'2, p. 64, small; two watery, scanty stools, tongue coated, still 
headache ; urine 38 ozs., pale, 1014, chlorides ^ vol. E. t. 98°'4, p. 68. 

15th. m. t. 98°, p. 64, feels belter; spleen still enlarged, extending from upper 
border of 9th rib to near an inch below the costal margin ; urine 36 ozs., higher 
coloured, 1015, acid, no albumen, chlorides^ vol. Weight loi^ lbs. E. t. 98° -4, 
p. 72. 

i6th. m. t. 97°"6, p. 68, weak; muscular pains have increased; the giddiness is 
less. Urine 36 ozs., 1012, acid, chlorides 5 vol. E. t. 98^*6, p. 68. 

17th. m. t. 98°, p. 68, soft, pains less, still some headache: the spleen is enlarged 
as before. Urine 36 ozs., paler, acid, 1012, chlorides | vol., no albumen, E. t. 
98°-5, p. 72. 

i8th. m. t. 98°, p. 64 : improvement slow. Urine 36 ozs,, 1012, acid, E. t. 
98' -5, P- 68. 

19th. m. t. 98° -4, p. 64, the pains are less ; liver of normal dimensions ; spleen 
still projec s slightly below the costal margin. Urine 34 ozs., acid, 1012, no albu- 
men, chlorides § vol. He wishes to leave, and is discharged for better air. The 
chart is appended in Plate IV., No, 3, at the end : pulse tracings were taken. 

Attack with Three Relapses, 

Case XI, — M., 30, Mussulman weaver, from N. India : admitted with 
fever of 7 days duration : he is so weak as to be unable to sit up ; has diar- 
rhoea ; headache, thirst, pains, tongue white and dry, abdomen slightly full, 
hepatic. tenderness : ro. t. 101°, p. 120 ; e. t. i03°-4, p. 126; spirilla in the 
blood. 8th day — m. t. 102°, p. 126, diarrhoea ceased, has splenic pain ; e. t. 
102°, p. 120. 9th day — m. t. 100°, p. 122, was delirious in the night, tongue 
brown in centre, hiccup, abdominal pain not more ; spirilla present but fewer, and 
several moving particles seen : e. t. 96°, p. 90, this was the crisis. There followed 
a smart rebound of temperature (secondary fever), which lasted three days, the 

F 



66 SPIRILLUM FEVER. 

hiccup and delirium persisting, with vomiting, injection of the conjunctivse, prominent 
fungiform papillse of the tongue, dryness of skin ; treatment of the symptoms and 
support ; on the fourth day the temp, became normal, and for three days longer he 
remained apyretic, the appetite being considerable. The first relapse then set in, 
being preceded by a mild paroxysm ; it lasted five diys and was of nearly continuous 
type : max. t. 104° 5, p. 132, about the middle of the attack : the spleen was then 
enlarged but not tender, abdomen tense, stomach irritaljle, soreness of the throat, 
severe general pains : hiccup and delirium soon after re-appeared, the tongue became 
brown and dry, there was hepatic and splenic tenderness and bilious vomiting ; crisis 
was moderate ; e. t. 98°, p. 108, and not followed by relief ; sweating moderate, 
much depression and persistence of delirium, vomiting and dryness of the tongue, 
some jaundice ajpeared. Secondary fever again followed, though less pronounced 
than after the invasion : he was prostrated, the heart's impulse and first sound being 
imperceptible in the lying posture : he complained of pains in the limbs and wandered 
in speech ; the tongue was shrunk, dry and brown all over ; and I noted the contrast 
between his state and that of a patient in a neighbouring co% who had depression 
without these typhous symptoms. The man now rallied ; there was some pulmonic 
congestion at first, and gastric irritability, with dry tongue, persisted for a few days 
longer : the appetite then returned, in spiie of the vomiting ; he expectorated a little 
blood : finally there was no complaint but pains in the calves of the legs. Fourteen 
days after crisis of first relapse the fever returned suddenly, about noon, without chills ; 
it lasted three or four days, and was pronounced ; bilious vomiting and slight jaundice 
returned, with increased pains : no delirium or hiccup : abdominal tenderness hardly 
marked : the crisis of this second relapse was pronounced, and not followed by a 
rebound. During the fever the urine was clear, pale, acid and free from albumen, 
sp. gr. 1012. Weakness, pains, cough lasti d for a few days, and then convalescence 
progressed : there was a burning sensation in the soles of the feet at night, and the 
knees still ached. Seventeen days after the last crisis slight pyrexia re-appeared, 
without chills ; there was gastric irritability and a red tongue, some headache, 
lumbar pains and thirst : these phenomena constituted the third relapse of two days' 
duration. Soon afterwards, the patient could not be persuaded to sty longer in 
hospital. 

In its general features this case resembles No. 3 : the Chart belonging to it is 
No. 4, Plate IV. 

J^afal Cases. — Instances of spirillum fever ending in death were 
nearly as often as not complicated with pneumonia, haemorrhages, and 
other lesions, giving rise to special symptoms of their own {vide the 
Chapter on Complications). As regards uncomplicated fatal cases, the 
majority of patients died about the time of febrile acme of the first 
attack ; and the symptoms during early days of illness, were not 
peculiar or strikingly different from those of ordinary marked infection. 
Fever was seldom unusually high or sustained ; but, on the contrary, 
often tended to be low or irregular, and in consequence the acuter 
fever symptoms less prominent : when pyrexia persisted to the last, the 
symptoms were those of the Acme of fever (zn'de that sub-section below) ; 
and when the blood spirillum continued to be visible with a declining 
or low temperature (as happened in about one-third of all casualty 
admissions of over a week's date), the symptoms seemed to me like 
those attending defervescence by Lysis (wde that sub-section below). It 
is remarkable that deaths at the stage of completed critical fall, at either 
invasion or relapse, were extremely rare ; although it might have been 
anticipated that the very great depression then suddenly taking place, 
would of itself tend to a fatal result. Lastly, whilst it was not observed 
that other individual signs and symptoms were peculiarly marked in 
fatal cases, yet there was commonly apparent an early depression of the 



ILLUSTRATIVE CASES. 6/ 

system and tendency to the typhoid state, with decided abdominal 
suffering, dyspnoea and cardiac exhaustion : {idde Chapter on Prognosis). 
Having thus pointed out several sources of information respecting 
this complex subject, it will suffice to add that in the Chapter on Mor- 
tality will be found other details needful for its entire comprehension. 
The following cases have been selected for general illustration. 

Spirillar Infection ending in unexpected Death. 

Case XII. — M., 20, one of a party of famine immigrants from Azimgurh 
(N. India), others of whom were seen and some had died, was admitted on asserted 
loth day of illness — t. 100°, p. 114, small, soft, regular; tongue pale, coated in 
middle, moist ; the face pallid, complexion being muddy ; abdomen full, being 
distended in upper zone, liver much enlarged and tender, spleen very large 
(reaching 2\ ins. below costal margin), less tender ; no stool for 9 days ; no erup- 
tion ; skin supple, sudamina in the axillae. Heart's action tumultuous, first sound 
not prolonged but attended with decided murmur ; second sound clear, impulse 
perceptible at scrobiculum cordis : pupils normal ; has throbbing frontal head- 
ache, aching pains all over body, much thirst, occasional vomiting, a bronchitic 
cough : the blood is very thin, pale brown in hue and swarms with spirilla. No 
previous history of splenic enlargement, but the lad presents the aspect of malarious 
cachexia: body-weight 1 00 lbs. Vesp. t. I03°"2, p. 132, full but soft; liver 
reaches to loAcr border of 5th rib and below to costal margin, its region is 
tender ; spleen reaches to upper border of 9th rib, and below 2 ins. below costal 
margin and 3 ins. from the median line, some tenderness here also ; and over the 
somewhat distended epigastrium : skin soft, sudamina beneath the skin ; lips dry, 
tongue still moist ; less headache and pains in limbs, more pain in back, conjunctivae 
sallow. There was some sweating at 11 A.M.: urine free, acid, clear, light -coloured, 
1012, chlorides \ vol., no albumen or sugar, bile constituents present. 

Next day, m. t. 101°, p. 124, full, firmer, tongue tending to be dry, lips dry: 
liver-dullness not increased vertically, still tenderness ; the spleen seems somewhat 
pushed up ; the epigastrium is mainly occupied by the right and left lobes of the 
liver, and is tender ; 2 stools during the night (after saline aperient), of bilious 
brown hue ; he slept, has slight headache and pain in the back and limbs, much 
thirst, some appetite; eyes yellowish; no sweats in night; urine 16 ozs., very pale 
and clear, chlorides reduced (^ vol. ), no albumen, bile-acids and pigments a trace : 
no vomiting, pupils rather dilated. Vesp. t. 102'' '4, p. 120, full, firm, regular; re- 
spirations 40 per minute ; tongue coated with a yellowish fur, but moist ; lips dry ; 
liver-dullness extends from upper border of 6th rib to 2 ins. below costal margin ; 
splenic dullness from upper border of 8th rib to i|in. below costal margin, and 3^ ins. 
from median line, epigastrium occupied by the hepatic lobes ; all parts here tender 
on pressure : no eruption or fresh sudamina ; one semi-solid bilious stool ; no head- 
ache ; pains in loins and limbs ; conjunctivse yellowish ; pupils slightly dilated : skin 
dry but not harsh, much thirst, eats his food ; urine of the day plentiful, pale and 
clear, 1012, acid. 

It is said he slept the early part of the night, then awaking asked for water, skin 
being warm; did not rise; then he became delirious and gradually sank at 3 a.m. 
7 hours after death I found extensive granular and fatty degeneraiion of liver, spleen 
and kidnies ; the heart was dilated and hypertrophied (weight 12 ozs., substance pale 
but firm) : the blood contained large granule-cells (endothelial or splenic) with fat 
globules in them ; also a few languid spirilla. 

Fatal Attack with Irregularly Developed Pyrexia. 

Case XIII — F.,30, hospital-matron in good health previously and on active duty, 
acquired fever in her ward (where part of an infected family was lodged and where 
the clinical clerk at this time probably caught his fatal infection). Second day, m. t. 
103 •°2, p. 114, small, the fever began with chills at 10 a.m. yesterday, and she per- 
spired freely^ 4 hours later, chest sounds normal ; abdomen free from fulness or 

F 2 



68 SPIRILLUM FEVER. 

tenderness, tongue moist, almost clean ; bowels free, no appetite, has headache, thirst 
and pains in loins and limbs, no jaundice : menses regular. Vesp. t. 98°"6, p. io8, 
fever subsided, but at 8 p.m. it returned with headache. Third day —m. t. 99° "4, p. 
104, bowels opened, has vomited twice, still headache : e. t. 98^*8, p. 104, as yet there 
were no symptoms to attract the special attention of the experienced native graduate 
in charge. Fourth day — m. t. 98° "6, p. 106, purged thrice and vomited twice, evacu- 
ations bilious : e. t. 101°, p. 104 : still no special symptoms. Fifth day — m. t. ioi°*8, 
p. 108, passed a quiet night, purged 4 times and vomited 4 times, no abdominal 
pain, grinds her teeth during sleep ; tongue moist, thinly furred white, has headache 
and pains in loins and limbs as before, not much thirst ; the belly seems puffed ; 
compound saniorine powder ordered, and cold to the head. Vesp. t. iOl°"6, p. 104. 
I found the woman restless and much distressed — her blood contained many spirilla. 
Sixth day — m. t. 99°, p. 108, free purging, no worms passed, no hepatic or splenic 
enlargement detected : she slept 4 hours (chloral given) pains of loins and limbs less, 
and less mental disturbance : skin clammy and she is low. At 8.30 the t. was 
101°: vesp. t. 99°, p. 114, she is much oppressed but rational, pupils rather con- 
tracted, there are two red spots on right forearm, none on the back, a doubtful one on 
the left forearm : tongue now dry, brown on dorsum and rough, red at sides and tip, 
skin soft. Seventh day — m. t. 101°, p. ixo, feeble and small, no sleep (in spite of 
chloral) and was delirious, one stool, conjunctivas yellowish, tongue brown but less 
dry, pains of limbs and back, no abdominal uneasiness, some crepitus scantily heard 
in right infra-scapular regkui of chest, heart's impulse and first sound very feeble ; 
skin perspiring, the headache is less and she sits up : is restless but tractable, eyes 
injected and heavy-looking, pupils decidedly contracted, grinds her teeth and wanders 
in speech at times : a few more petechial spots on front of left shoulder. Vesp. t. 
101° -4, p. 128, full but very compressible ; she lies on back, often screaming and 
grinding the teeth, will not open the mouth, but tongue felt to be dry, head not hot, 
skin moist, no stool, urine passed in bed ; abdominal fulness, tension and tender- 
ness ; she seems hysterical but doubtless the brain is affected, pupils dilated some- 
what, very sluggish, the head turns to left side and possibly some facial paralysis, but 
no spasms seen : enema, cold to head, and sedatives ; food. Later on the temperature 
did not rise ; skin moist, no change, bowels moved, swallows with facility. Eighth 
day — m. t. ioi°'2, p. 124, feeble : little change, but pupils contracted, tongue dry 
brown and shrunk, no fresh spots, no sleep and still moans, yet is not unconscious, 
urine and stools passed in bed ; a little sweating in the night ; abdomen full, tense 
and tender ; heart's first sound audible, though faint. Vesp. t. 103°, p. 140, small, 
regular, skin moist, some fresh spots on the chest, abdomen tympanitic and not 
tender, splenic or hepatic enlargement not detected, lungs seemingly unaffected. 
Pupils still contracted, she is nearly insensible, but can be roused ; breathing 50 per 
minute, thoracic and jerking, no spasms ; the typhoid state has not yet ensued. 
Later on the t. rose to 104° and p. 150, skin dry, pupils much contracted, (the pin- 
hfjle pupil) nd much conjunctival injection, with ecchymosis at upper half of right 
eyeball, just beyond the normal edge, spasms of face and limbs, restlessness and toss- 
ing of arms, but not active delirium or entire unconsciousness : 10 ozs. of high- 
coloured, clear urine drawn off ; procidentia uteri : symptoms of coma towards mid- 
night, and death at 2 a.m. Autopsy 6 hours afterwards — Brain and membranes 
congested, with small petechial extravasations at vertex on left parietal and right 
occipital convolutions, and in right Sylvian fissure ; brain substance soft, convolutions 
shrunken, and the moist membranes easily removed : mucous membrane of stomach 
showed many petechias along the lesser curvature, and was smeared over with viscid 
mucus, streaked black, which also extended into the oesophagus ; there were petechise 
in the small and large intestine, common bile-duct free ; uterine mucosa pale : there 
were many sub-peritoneal extravasations of small size : liver firm, very large and very 
pale, a group of blood spots in left lobe over the stomach, bile abundant ; spleen 
very large, dark, firm ; kidnies rather large, flabby, mottled, both contained petechial 
extravasation. There were one or two hemorrhagic spots beneath the parietal layer 
of pericardium ; muscular substance of heart pale and friable; lungs inflated, there 
were sub-pleural and sub-mucous petechial spots. 



69 



CHAPTER III. 

GENERAL PHENOMENA : PRODROMATA, PHYSIOGNOMY, BODY-WEIGHT J 
ACME, CRISIS AND LYSIS. SPECIAL SYMPTOMS : HEADACHE, PAINS, 
THIRST, APPETITE, VOMITING, SWEATS, SUDAMINA ; THE TONGUE 
AND STATE OT BOWELS. HEART, PULSE, LUNGS ; LIVER, SPLEEN ; 
URINE. 

Prodromata. — Particular interest attaches to the state of the patien 
I, 2 or 3 days prior to the onset of fever, because on these dates the 
spirillum first appears in the blood, and some contemporary constitutional 
disturbance might be anticipated. 

Precursory symptoms are such as appear de novo and spontaneously; 
they are mostly of subjective character, seldom pronounced and not 
always the same : as they may be overlooked or forgotten, it is possible 
they are never altogether absent. When present, they should be dis- 
criminated from signs of impaired health, so common in famine-fever 
patients prior to first attack ; and from the relics of previous paroxysms, 
in the instance of relapses. It seems likely that the more defined symp- 
toms are truly initiatory; such are defective appetite, constipation, seldom 
diarrhoea, inability for sustained exertion of all kinds, nmch weariness, 
pains in the back and limbs, headache, flushing, chills, sweats {at night) ; 
a sense of burning in the eyes, or in the palms and soles, fixed neuralgic 
pain, hemicrania, vomiting, turgescence of the spleen (without pain) ; 
and the minuter changes of temperature, pulse and urine indicated 
below. 

Such symptoms appear during the later specific incubation-period ; 
during the earlier part of this period when the blood is not visibly in- 
fected, they are unknown : though occurring when the blood-contamina- 
tion becomes evident, they did not show any fixed relation to the new 
blood-state. If the latter be obscure or absent, the symptoms, too, may be 
almost wanting, as in the following instance : — H, V. C. was accidentally 
inoculated at an autopsy : no change noted till 4th morning, when awoke 
suddenly with headache and slight abdominal pain, not limited to the 
spleen, possibly some pyrexia, but an hour later t. 98° '2, p. 72, and the 
specimen of blood taken did not show the spirillum : 5th day, dreams 
at night, some cough (? a cold in the head) ; 6th day, nothing definite 
and the late symptoms may have been incidental ; 7th day, a feeling of 
slight weakness, no spleen ; at duty as usual : 8th day, also out of sorts, 
but still to duty and had hopes that the risk was over ; blood free from 
contamination : at 3 p.m. headache and inability to work, no chills, fever 
beginning t. 100° '2, p. 80. The spirillum was not found till next day, 



70 SPIRILLUM FEVER. 

but may have been overlooked by the patient : the ensuing attack was 
moderately severe ; no distinct relapse. For other quasi-negative ex- 
amples at beginnirg of the relapse, see the cases above detailed. 

In my experiments on the Quadrumana, the monkeys always seemed 
well until the access of fever ; though at the autopsy of three animals 
some slight organic changes were noted as already present during the 
specific incubation-period. In hospital, the more intelligent patients 
seldom (e.g. not one-half of them) made more than a vague mention of 
prodromata ; their statements are, however, recorded here for future 
use : at present, it is uncertain whether or not any of the premonitory 
symptoms named are common to several fevers, or peculiar to the 
spirillar ; their relation to preceding kind of infection and ensuing 
attack, and to the co-existing blood-state, have also to be accurately 
determined. The relationship to preliminary aguish attacks is con- 
sidered elsewhere. 

Perturbations of Temperature and Pulse as premonitia.- — It might 
be supposed that precise objective data would be most likely to furnish 
definite information regarding pre-febrile changes ; and doubtless this 
opinion is correct. At present, however, such data are very scanty, the 
following being a summary of those available : — Invasion-attack : in my 
own case no changes of temp, were felt, nor did the pulse vary, so far 
as was ascertained. First Relapse — the ordinary chart of the woman 
Case IX. furnishes signs of a sinking of temp, on 2nd day before 
onset of fever, the pulse also declming ; and the 3-hour chart shows 
this depression very evident on the ist day before, pulse still less fre- 
quent ; spirilla in the blood ; prodromata obscure : vide Plate 2. Plate 3 
displays a longer ist interval, with decided decline of t. and p. until 
near the relapse ; yet these changes do not seem connected with ascer- 
tained state of the blood, excepting that with permanent advent of the 
spirillum there occurred distinct perturbations : other signs obscure. 
A few other instances are available of ascertained pre-febrile infection, 
when only bi-daily observations were made, and consequently nothing 
precise learnt of temperature and pulse movements : here, too, the pro- 
dromes were not marked. For a slight depression before advent of a 
quasi-latent relapse see the chart of the woman K., Plate i. Chart 9^. 
I have known the pulse alone rise from 76 to 100 for two days before 
relapse, when the spirillum was present: temp, at 98"-98°"4 F. 

Comparative experiment has furnished useful data of temperature 
(other details being inaccessible) during the incubation-period of first 
attack ; and these accord with the human data in so far as showing, with 
much variability, a tendency to decline of body- heat just prior to 
febrile onset . An early analysis of 1 1 examples may be summarised as 
follows— inoculation being followed by a slight decline, there ensues a 
decided rise next day, or on the third, with a delayed night minimum, 
the blood at this time being free from visible contamination ; upon 
appearance of the spirillum, however, the temp, is found to subside 
below the mean, or to become more level, and then just prior to fever 
there occurs a decided fall, or else a preliminary rise : high pyrexia 
coming on quickly afterwards. 

General Aspect and State during Fever. — Usually the patient takes 



BODY- WEIGHT. 7 1 

to bed on the first or second day of illness, and there lies supine until 
near the end of attack, being greatly indisposed to move ; but under the 
stimulus of necessity many individuals keep afoot, and according to 
their own account (which dates of fever confirmed) persisted at work or 
on long journeyings ; whence it would appear the early prostration is 
not so absolute as in typhus proper. Such cases correspond to the 
' ambulatory ' forms of continued fever. 

During the course of high fever, the physiognomy of patients was new 
to observers at Bombay, and so striking as sometimes to be recognisable 
at a glance. After two or three days the visage acquires a livid or 
bronzed hue, which is not like the effect of sun or dirt, or quite the 
flush of ordinary fever or of thoracic disease ; but is comparable rather 
to a combination of a dusky typhus hue, with the semi-translucent tint 
of native skins. It was seen best in Hindoo agriculturists and wander- 
ing mendicants, and less well in the more pallid Mussulman weavers 
and town residents : in black skins it was barely visible. Turgescence 
of the integuments was rare : the conjunctivae were clouded and seldom 
injected, the eyes heavy rather than bright or suffused ; the pupils 
large rather than contracted. 

More significant is the weary, haggard or hapless expression of the 
patient : features shrunk or drawn, with a slight frown and raising of 
the nostrils and upper lip indicative of distress, whilst the attention is, 
as it were, concentrated inwardly. Sometimes the expression was very 
stolid. 

This remarkable ' facies ' seemed most striking when the blood was 
charged with the parasite, and the abdominal symptoms pronounced. 
Even infants showed it : and all patients best during the severer invasion- 
attack : I do not know that it had a prognostic import. At relapse the 
face was often pallid and shrunken, and the aspect distressful, as if 
from pyrexia alone. The presence of complications modifies these 
appearances. 

The posture of the sick may be supine, with the knees drawn up ; 
or lateral, with the legs and trunk bent so that the patient lies curled up; 
he changes his position from side to side, unless either liver or spleen is 
pre-eminently tender. 

The contrast here with ordinary typhus is noteworthy ; and I may 
add that inoculated monkeys during spirillum fever assumed a similar 
bent form, which was not presented by those animals suffering from other 
febrile infection. 

When delirium supervenes the general aspect becomes that of direct 
blood-poisoning, and I have known this state closely simulate that of 
poisoning by Dhatura seeds : in the case referred to the man shortly 
died ; and without delirium, the distress may become mortal, as I have 
also witnessed. See ' Acme ' and ' Crisis ' below, for other details. 

Body-weight. — This furnishes a ready test of the effects of specific 
fever. Robust individuals nearly regained their weight a few days after 
the end of first attack ; not so the weaker subjects, and in case of 
secondary fever at this time — thus the man whose case is detailed above 
(H. A., No. X.) weighed 99 lbs. av. at the beginning and end of the first 
apyretic interval, having gained nothing in weight during the ordinary 



72 SPIRILLUM FEVER. 

restorative period. Brief relapses leave their mark, one of a day's dura- 
tion bringing down the weight i lb. , which was not regained for two days 
more ; and longer ones, even when uncomplicated, produce a decided 
effect. Thus in the man H. A. the weight was 99 lbs. on first day, 
98 lbs. on third day, 97;!: on the fourth, 96I on the fifth, there being a 
loss of 2 1 lbs. during four days' pyrexia; promptly with main critical fall, 
sweats attending, the weight sank to 93I lbs., and the depression with 
sweats continuing, though not excessive, it was next day 9o|- and on 
third day of fall to the lowest point, it was 89 lbs., showing a loss of 

10 lbs. or -i of body- weight. In the woman's case (F., No. IX.), the 
patient weighed 76 lbs. on evening before relapse began, and 66 lbs. at 
the fall, showing also a loss of 10 lbs , or at least ^ of body-weight : the 
regain was hardly perceptible at first, and after a week at the rate of 
only ^ lb. a day ; it attained to i^lbs. daily at the end of a fortnight 
(body-weight 74 lbs.) and continued to advance. From these few data 
it appears that emaciation takes place chiefly at the end of the febrile 
attack, when copious sweats occur ; that during continuous pyrexia it 
may not be considerable ; and that recuperation after fever is but slow at 
first. When the infection has been severer than usual, rallying is de- 
layed ; thus a young man weighing about no lbs. at beginning of illness, 

11 days after relapse weighed only 95 lbs., showing a loss of 14 lbs. even 
then. When local inflammation concurs, doubtless the emaciation in- 
creases ; and wasting must be regulated by many conditions besides 
fever, which will be obvious upon reflection. 

After the crisis when the patient begins to move about, his emaciated 
and weak state may remain hardly less characteristic : muscular debility 
is often considerable ; I have known dislocation of the lower jaw occur 
almost spontaneously. Convalescence was commonly slow at first, and 
it has been already stated that the pulse for a time declines in frequency 
after crisis. 

Acme of Fever and the Perturbatio Critica. — At or near the close 
of the attack, the febrile and general excitement commonly become 
augmented ; and fresh symptoms, more or less urgent, make their ap- 
pearance. This final paroxysm may be so slight and brief as not to 
impress patient or attendant ; and when it occurs, as is usual, during 
absence of the medical officer, it is apt to be overlooked : judging from 
my last series of 60 cases, it is but rarely absent. There are, indeed, 
many degrees of this exacerbation, and the time of its occurrence varies 
much : in mildest form the body-heat and, less markedly, the pulse 
may almost alone be excited, but commonly there is increase of head- 
ache, thirst, body-pains and abdominal uneasiness, the tongue quickly 
becomes dry ; deafness, epistaxis, giddiness or delirium ; dyspnoea 
with a dusky or cyanotic aspect ; dysphagia, fulness and tenderness in 
the upper abdominal zone, hiccup, vomiting, a sense of distension ; and 
in addition much depression, will on different occasions be noted. 
Usually a remission of fever takes place just before the exacerbation, 
and it may be decided : this point is well worthy of notice. The suc- 
ceeding rise of temperature, as ordinarily estimated, varies from 1° to 
5° F., and it holds no fixed relation to the attendant symptoms, for I 
have seen the thermometer at 105° or 106°, with but little distress. 



PERTURBATIO CRITICA. 73 

especially in relapses of both young and old : and, on the other hand, 
at 103° there may be much suffering : as a rare event, more than one 
exacerbation occurs, and then the final paroxysm is seen to be only the 
last of a series. At this time the pulse becomes very frequent, rather 
before and until after the acme of temperature ; it is very compressible 
and may be irregular, intermittent or dicrotic ; 140 or 160 pulsations 
per minute are not very rarely counted ; the heart's action is invariably 
weak : the respiration is much quickened, and in degree possibly peculiar 
to the spirillum fever ; yet with 50 inspirations per minute there may be 
but little distress, at least in youth. The abdominal signs vary not less 
than the rest ; spleen, epigastrium and liver, in different cases, being 
most complained of, and I could not detect a fixed ratio between the 
implication of spleen or liver, and the general suffering: the urine seems 
unaffected, or at most contains traces only of albumen. With the dys- 
pnoea some degree of impaired resonance may be detected at base or 
apex of a lung, and incipient pneumonia may be suggested ; yet with 
the crisis complete relief will arrive. Epistaxis occasionally occurs at 
this juncture, heat of head (without headache) has been noted with it : 
the pupils are not affected necessarily ; the skin is dry ; body-aches 
may be so much increased, that the patient dares not move : and, in sum, 
his general aspect becomes striking — the harassed look, pinched features, 
hurried breathing, prostration ; often distress, restlessness and even 
delirium, forming a conjunction not seen at Bombay during late years, 
except in these cases of relapsing fever. When the attack ends gradually 
or by lysis, the acme becomes, as it were, anticipated, and the critical 
phenomena are mostly wanting. 

In about one-fourth of cases under my care there was clear intima- 
tion of a perturbaiio critica^ ushered in by chills or pronounced rigors, 
of a few hours' duration, at most, and immediately preceding the crisis. 
At this time the above-named symptoms were very prominent, yet not 
different except in degree from those of ordinary acme ; and since the 
chills are not quite peculiar, I infer that this phenomenon naturally 
belongs to the category of events attending the sudden close of spirillar 
blood-infection. In addition to the example afforded by the woman's 
case quoted above — as No. IX. — another instance is here described, as I 
saw it ; and a third, copied from the J. J. Hospital records. 

These phenomena have been seen at all ages beyond that of infancy; 
and in both sexes. The illnesses in which they occurred were simple, but 
well defined \ the prolonged, low, typhus-like and complicated forms 
seldom displayed them. It happens that most of the attacks were 
relapses, and this preponderance may not be accidental. 

Diagnosis. — For obvious reasons, it might be desirable to prepare 
for the acme and be made aware of its presence : as the patient himself 
may not be in a condition to furnish the subjective signs, his general 
state may then be considered with reference to history of the case and 
previous duration and course of illness ; a late remission not attended 
with persistent relief may presage the final exacerbation. Actual symp- 
toms are almost characteristic, especially those of the perturbaiio critica; 
the temperature commonly rises high, but its height m. or e. is not an 
absolute guide to the stage of the case. The aspect of the blood is 
almost characteristic : see Sect. 3, Chap. I. 



74 SPIRILLUM FEVER. 

I might here quote for illustration my own late attack, during which 
I remained in my rooms for 4 days, and then in anticipation of the 
final rise was conveyed to quarters in the hospital ; the same night, 5th- 
6th day of attack, great distress and delirium set in, the only relief at- 
tainable being from constant sponging with iced water (temp, after this 

The influence of local complications must be considered ; it may 
tend to concealment of the acme ; but the blood- condition would still 
be available as guide, and particular symptoms could be referred to their 
probable origin. 

Prognosis. — Owing, doubtless, to the brief duration of stress, this 
is more favourable than might be anticipated ; yet the truly critical 
character of the epoch is clearly shown by the fact of more than 54 
per cent, of all deaths happening at this time of invasion-attack. It 
has seemed to me that a fatal result might occur in any pronounced 
case at this stage, and often it appears to be really contingent ; nor 
do autopsic revelations always dispel this view. Upon comparing the 
symptoms of fatal and surviving instances, a similarity in certain re- 
spects is perceptible, as regards troubles of the circulation and respi- 
ration, and state of the abdominal viscera ; with consequent general 
suffering. My data show that besides the depression, dyspnoea, moan- 
ing, restlessness and semi-consciousness, there soon follow before 
decease the more general changes pertaining to particular modes of 
death : nor are the above-named symptoms wholly peculiar in them- 
selves. No more, therefore, than a general resemblance in the follow- 
ing examples could be looked for : in other instances enfeebled patients 
died exhausted before acme of attack, and some from cerebral haemor- 
rhage probably at this stage supervening ; the symptoms in both 
series being modified accordingly. The common connecting link of 
all cases, seems to be formed by the state of the blood at acme of the 
fever. 

Symptoms at acme of Specific Fever. 

Case XIV. — M., 35. 4 P.M. t. i05°-6., p. 132, resp. 26; a little sweating, no 
headache, much thirst, pains in loins and neck, no delirium : an hour later I noted — 
there is much distress and he wanders in his talk, but is tractable : breathing quick 
and laboured, as if air entered the lungs- with difficulty, the chest is fully expanded, 
the left lung seeming to encroach on the pericardium, pushing the heart over to the 
right, respiration is rather harsh, no dullness on percussion : the left side of the chest 
measures ^ inch more than the right ; is all this left predominance due to enlargement 
of the spleen ? Heart-impulse feeble, but pulsations are quite perceptible at the tip 
of the sternum and rather to the r. side, as if the r. side of the heart were beating 
forcibly ; the second sound is alone heard distinctly, there is no murmur with the first 
sound over the cardiac region ; at the base, the second sound is alone heard ; along 
the aorta there is a sound which might be called a murmur — a rumbling or friction 
sound which renders the second sound here indistinct, and suggests the idea of a 
feeljly acting ventricle : it is not heard more to the 1. side than to the right {i.e. is not 
produced in the pulmonary artery chiefly) : area of cardiac dullness extends more to 
the right than usual and is elongated transversely ; it blends with the liver-dullness. 
Spleen — is decidedly enlarged but it does not extend beyond the costal cartilages ; ten- 
derness here. Ijver — is not much enlarged upon percussion, it may be pushed up- 
wards by the distended stomach, tenderness here. Stomach — distended with air and 
tender : no gurgling or tenderness in r. iliac fossa. Urine of the day- 18 ozs., high- 



PERTURBATIO CRITICA. 75 

coloured, clouded, no sediment, acid, loio, chloride 5 vol., albumen none. The 
blood contained several spirilla at this time, which were also found 6 hours later, 
disap earing with the great fall of temperature which then ensued. Crisis began 
between i and 4 a.m. 

The small monkeys of my inoculation experiments did not seem to 
suffer especially at the acme ; yet here it may be observation was defec- 
tive ; and it should be remembered that without unceasing attention the 
data requisite for absolute precision cannot be procured. 

Uncomplicated Fatal Cases dying at close of Invasion-attack. 

Case XV.— F., 14, condition fair ; the most urgent symptoms refer to the upper 
abdominal zone : drowsiness on the 7th (last) day ; m. t. I03°'6, p. 140 : at 2.30 
P.M. t. l04°-6, p. 160, resp. 36, she was then nearly unconscious, pupils dilated and 
fixed, breathing shallow, pulse barely perceptible ; there is great tenderness of the 
abdomen on pressure, and she screams on being touched there : death in four hours. 
No spirilla in the blood, but large granule cells, with endothelium ; no coarse post- 
mortem lesion. 

Case XVI. — M., 22, clinical clerk, on estimated 6th day of invasion-attack m. t. 
I03°'4, spirillum not seen by Mr. S. A.: e. t. i04°-4: 7th and last day, m. t. lo3°-4, 
no spirillum ; the pulse had risen from 130 to 140 : in addition to the pyrexial symp- 
toms were some jaundice, an eruption of pink spots, diarrhoea, cough ; then less 
headache, anxiety of countenance, tendency to stupor ; finally, skin moist, evacua- 
tions passed in bed — ' lips moist, tongue moist though brown, eyes bright but only at 
intervals intelligent, pupils slightly contracted ; he occasionally turns on the side and 
moans ; the chief feature is cardiac weakness, pulse hardly perceptible and uncount- 
ably frequent, both sounds of heart audible though rather muffled ; no cough or dys- 
pnoea, resp. 70j shallow, chiefly abdominal ; abdomen full, tense and very tender over 
the spleen (projecting 2 inches) and liver (rather less enlarged downwards), stomach 
distended, much thirst, no hiccup or vomiting ; the lad is not in the typhous state ' 
(MS. notes). The blood contained many \\hite cells and an equal number of larger 
pale, granular -cells ; red-discs shrivelled and heaped. An hour and a half later 
sudden insensibility came on, with loud moaning, cooling of the limbs, skin of trunk 
hot and dry ; death : at the autopsy, few palpable changes, the chief being spleen 
enlarged to 17 ozs., infarcts not noted. 

The Phenomena at Perturhatio Crltica. 

Case XVII. — M., 25. Admitted late in invasion-attack : symptoms pronounced ; 
on last m. 6 A.M. t. 102° -4, p. no, much headache, thirst and giddiness; tongue 
white on dorsum, red at edges, moist ; cough with scanty sputum, no pain in chest, 
yet respirations "jo per min. abdominal and shallow : fulness and tenderness over 
epigastrium and liver, not over the spleen, pains in loins, legs and arms, three stools ; 
was delirious during the night, but tractable. Two hours later t. 105° and he was 
shivering strongly, the cot shaking with the rigors — sweating followed and at 4 P.M. 
t. 95° '2) p. 62, no collapse and he is sitting up at comparative ease ; drowsy, no 
dyspnoea. The succeeding relapse was very severe : the t. declined on 6th day, the 
typhoid state threacening and the spleen becoming much enlarged : 7th day at 5 A.M. 
t. ioo°-6; 6.20 A.M. t. 103°, p. 120, soft, regular; strong chills at 6, now much 
headache and distress, tongue brown and dry, stools and urine passed in bed ; I saw 
him soon after and noled the great change for the worse since last evening — dyspnoea 
urgent, resp. 60 per min., breath cold, chest expansion imperfect, heart's action very 
feeble, pulse very rapid though regular, pupils dilated ; he was barely conscious, and 
seemed dying from clots in the heart : blood free from the spirillum. 10.30 A.M. 
t. 99° : II -30 t. 98° "4, p. 106, resp. 46, some sweating, less distress, he looks drowsy; 
2.30 P.M. t. 96' "4, p. 90, resp. 40, skin moist: 5.30 p.m. t. 96°-2. p. 88: next 
morning he had rallied further, t. 97° '4, p. 80, resp. 36, no dyspnoea, still abdominal 
soreness, the spleen smaller and harder : he was greatly reduced in aspect yet 
promptly rallied. 



J6 SPIRILLUM FEVER. 

The Crisis.— Amongst survivors, defervesence is thus abrupt in at 
least 90 per cent, of cases. 

True crisis being limited to the terminal period of specific fever, all 
pseudo-crises or previous declensions of pyrexia, however considerable, 
will be found to be of different relationship. Critical symptoms may be 
somewhat i like at both true and spurious events ; but are much more 
pronounced when specific blood changes concur : amongst themselves, 
the several symptoms variously predominate. The general state of de- 
pression corresponds, generally, to degree of decline of pyrexia ; this is 
not, however, always so, as my cases show. The course and duration of 
crisis differed, even among instances otherwise not unlike ; yet I would 
specially mention that the general symptoms were almost invariably 
severe when the critical descent was slow to begin, and in its earliest 
course particularly — such prolongation of this stage approximating to fall 
by lysis. After the main subsidence is effected, depression may become 
somewhat intensified, or the lowest state be maintained for a day or 
more, with results either serious (as when active delirium ensues) or 
virtually mild ; and the restoration of strength and a quasi-normal state 
is attained with varying promptness, its general rapidity being one of the 
marvellous features of the spirillar infection. 

It did not appear that towards the extremes of age the critical symp- 
toms were more marked or otherwise diverse : older subjects did not 
suffer more, rather to my surprise : experience with infants was limited. 
Sex — females were not affected more than males at this stage of spirillum 
fever. 

Weak subjects suffered most with the same degree of crisis ; the 
robust oftener showing extreme depression with comparatively slight 
constitutional exhaustion. The influence of caste and race, or of occu- 
pation and diet, was not apparent. As regards first and subsequent 
attacks, although the ranges of temperature at the close of relapses are 
somewhat greater than at end of invasion, yet in general the critical 
symptoms were not so pronounced ; especially when, as usual, the 
duration of the relapse was short : and whilst there is no essential 
difference to be noted in the character of these symptoms in early or 
late specific attacks, the sweats may be more copious and emaciation 
evident at the end of first relapses ; then, too, the critical changes are 
apt to be more sudden, and convalescence earlier. A minuter com- 
parison could be made only between the longer relapse, and ordinary 
invasion ; for it seems that it is the duration of the fever in the spirillar 
infection, which {cceteris paribus) practically determines its clinical 
effects upon the frame. In even marked recurrences the general symp- 
toms are seldom quite as severe as at first, notwithstanding the debilitat- 
ing eff"ects of a previous attack ; but the spleen may be more impUcated, 
and the signs of simple depression as pronounced, even when relapse 
has lasted only a day or two. 

Amongst Moha r.edan weavers with prolonged, low fever and less 
pronounced changes of temperature, the critical symptoms often partook 
of a typhous character ; yet exceptions occurred when I least expected 
them : and whilst it may be surmised that the late epidemic in its course 
changed from the sthenic to the asthenic type, still in the last seen cases 
(1880) these symptoms were (like the blood-infection) hardly less marked 
than in 1877. 



CRISIS. JJ 

In a clinical sense, the phenomena of crisis maj^ be regarded as 
composite in character ; there being present at this epoch, a certain 
degree of febrile exhaustion and a state approaching to that of collapse 
or shock. The first-named element not being peculiar, further comment 
is unnecessary ; but that the second is also of mixed nature is indicated 
by the fact of depression being sometimes considerable with only a 
moderate critical defervescence, whilst, on the other hand, with a marked 
crisis anything like collapse may be wanting. In fact, the crisis of 
spirillum fever is accompanied by remarkable changes in the blood, as 
well as by a sudden cessation of pyrexia. 

As clinical varieties of this stage, there were noted numerous in- 
stances — the majority, indeed, in which there ensues prompt and almost 
complete reUef from previous suffering ; or the shock symptoms will 
predominate, as in Cases XVIII. and XIX. quoted below ; or, lastly, 
with even considerable decline of temperature, some febrile pheno- 
mena may persist, resembling those of lytic defervescence. Analogous 
phenomena in other fevers will be alluded to under the head of 
Pathology. 

As a summary of my notes on the terminal symptoms of spirillum 
fever, I may add that as probably peculiar to its crisis in their conjunc- 
tion and comparative frequency, are the dilated pupils, persistent thirst, a 
tongue now becoming dry, still quick pulse and breathing, booming 
heart-sounds, supervening pulmonic congestion (bronchial or paren- 
chymal), abdomen tender, with still enlarged viscera in its upper zone 
and sometimes retracted or distended, hypogastric uneasiness, retained 
fteces, retained or suppressed urine ; eyes injected, active delirium, a 
subjective sensation of abdominal fulness or internal heat, of tingling 
in the limbs, pains in locomotive organs ; an irregular distribution of 
body-heat, an eruption of pink spots, hunger, striking emaciation, 
oedema of the insteps or dorsum of the feet, epistaxis, melaena, and as 
early sequelae pneumonia, parotitis, jaundice, diarrhaa or dysentery. 

Common critical symptoms may be unusually pronounced, when the 
patient during fever has been weakened by diarrhoea, vomiting or sleep- 
lessness. 

The comparative predominance of usual and the less common 
symptoms is considered under the headings below ; and so the attendant 
state of blood ; and the relations of crisis to rebound or second- 
ary fever, as well as to localised complications, in surviving and fatal 
cases. 

Diagnosis. — In ordinary specific attacks, whether first or recurrent, 
there is seldom any difficulty in recognising the end of fever by both 
general symptoms and state of the blood ; the abrupt cessation of fever 
and disappearance of the spirillum being distinctive. But it is necessary 
to bear in mind that either of these phenomena may occur separately, 
and that the only proof of a true crisis is the non-existence of visible 
blood-contamination : thus, during specific fever the ordinary remissions 
may be so prolonged as to become intermissions with sweating and 
exhaustion, which could hardly be distinguished from a critical event 
except by remembering that invasion-attacks rarely last fewer than 4 
or 5 days and are not liable to such intermission, whilst the relapses 
become increasingly intermitting in character. Moreover, irregularities 



78 SPIRILLUM FEVER. 

of pyrexia and other symptoms attend the close, as well as beginning 
and course of an attack ; thus, the perturbatio critica (or final paroxysm) 
may be so isolated from the previous sustained fever, as to become sepa- 
rated by an interval closely simulating the true crisis — such event being 
commonest in the relapses : or just after the true crisis there may arise 
an additional paroxsym, also resembling a part of the main attack — this 
event likewise being commonest in relapses, though I have seen it more 
than once after both primary and recurrent attacks : these rarer phe- 
nomena cannot be foreseen, and at first they were discriminated with 
difficulty. On the other hand, the true crisis may be not only recog- 
nised, but confidently foretold from the state of the blood ; for with 
absence of the spirillum, specific fever ceases for good. 

That this fever may terminate without there being apparent any 
critical event, was several times noticed in attacks complicated with 
pneumonia, hepatitis, and some other acute inflammations. Here the 
symptomatic fever either co-existed with, or so promptly followed, the 
spirillar, that there was no visible interruption of continuous illness, or 
so little as to be seemingly insignificant ; and the microscope alone 
could determine the date on which specific blood-contamination ceased. 
I have elsewhere shown this confusion of febrile symptoms may obtain 
at the beginning of a relapse ; and it then becomes somewhat greater, 
for according to my experience the true crisis seldom fails to be indicated 
by some relief of febrile distress (however momentary or slight), even 
when symptomatic pyrexia runs high. It is very rare that a primary 
attack certainly lasts longer than 8 days (whatever time patients may 
name) or less than 4 or 5 ; relapses being much more variable closer 
attention may be needed to detect their critical termination. During 
irregular invasions and intermitting relapses, whether first or second, 
whilst the temperature- range is large, yet the pulse varies less ; general 
or local (even splenic) symptoms may be hardly characteristic, and a 
pseudo-crisis not be distinguishable from a true crisis without blood- 
scrutiny : and considering that the infection in these instances is seldom 
very abundant, the first requisite to accurate diagnosis is a thorough 
carrying out of such scrutiny. 

Prognosis. — I could not but observe that all the many patients seen 
passing through extreme degrees of crisis recovered even promptly, and 
seemed to suffer no evil consequences from this wrench to the system : hence 
the inference that prognosis is not to be guided alone by appearances, 
however suggestive. The contrast here is great with the undoubted risks 
accruing at the acme of febrile attack. It is possible my large series of 
fatal cases is incomplete, yet, as it stands, there is hardly a death at end 
of marked crisis, or even at its beginning, unless some complication 
were present such as of itself would account for decease : therefore 
mere exhaustion must be rarely very serious in hospital, whatever result 
outside may follow, from the want of artificial warmth, stimulants and 
food. I note that amongst 109 recorded casualties there were only 9 
instances of death at end of fever with symptoms approaching those of 
critical prostration amongst survivors : and since these include cases of 
decease during lysis and with local complications present, it results that 
no evidence is available of death from critical shock or collapse alone. 



CASES AT CRISIS. 79 

This circumstance indicates that the abrupt termination of spirillum 
fever is truly a relief-process tending to health. 

To the following illustrations I have added a striking case of prema- 
ture and repeated exhaustion, as a sample of clinical phenomena still 
imperfectly understood. 

Cases illustrating the state at Critical Defervescence. 

Case XVIII. — M, 25, condition fair; admitted at mid-invasion period, fever 
high with remissions, crisis not so direct as usual, sweating scanty and irregular at 
first; 7tli day m. t. 102°, p. 112, decline in progress, skin moist with sudamina in 
neck and axilla, giddiness, no headache or pains, urine free : e. t. 96° "4, p. 80, the 
main fall with much sweating at noon. Next day m. t. 94° "4, p. 72, feeble, regular, 
skin clammy, tongue dry, thinly coated white in middle, red at sides and tip, vomiting 
in night of bile, urine free, no stool, slept, deafness and giddiness, much debility and 
emaciation within the last 24 hours ; e. t. 94°"2, p. 84, feeble but regular, skin 
clammy, countenance dusl:y, oppressed, eyes sunken, voice low, has not taken food 
or medicine (stimulants) since morning, no thirst or headache, giddiness, no stool, 
urine free, vomited twice during daytime — a remarkable condition, abdomen collapsed 
and not tender, he looks like a corpse and his voice is barely audible, his complaint is 
that he cannot eat, the intellect is perfectly clear, but he seems hardly to live ; no 
distress, the sta'e being one of pure exhaustion, such a never before seen ; heart's 
sounds clear, the first being very weak ; there is irritability of the stomach, so that he 
cannot retain liquids (notes at bedside). A slow and halting advance to the normal 
state then began ; the temp, of the trunk rose before that of the limbs, especially the 
lower ; the pulse gained strength gradually rather than rapidity ; no sweats ; hiccup 
came on for a time and the urine was passed in bed once, vomiting continued ; but 
no complication being present, in six days he had rallied : four days later a smart 
' relapse ' set in ; at this date it was noted that desquamation of the whole body was 
taking place. He was much exhausted by the second attack, a few pink spots 
appeared at its close, and the spleen was much enlarged and tender : rallying was 
fair, the chief complaint being pains in the calves on movement. This man's wife and 
young family were admitted with fever from the same house ; none showed the same 
critical depression : the nurse and clerk of the ward they were in caught the disease, 
and both of them died in a few days. 

Case XIX. — M., 40, admitted towards the close of supposed first relapse : m. t. 
102°, p. 104 ; e. t. 99", p. 92, feeble but regialar, is perspiring, sweat acid in reaction: 
next day m. t. 94"^ (estimated), p. 60, feeble, regular ; tongue brownish, moist, no 
headache or pains, but simple weakness ; the fever had subsided in the night with 
much sweating, no delirium — heart's action extremely feeble, impulse not perceptible, 
first sound hardly heard at apex— a remarkable state, the body being like that of a 
corpse, the skin shrunken, wrinkled and clammy ; the man is placid, can move the 
body about and speak audibly : pupils rather contracted ; the spleen seems smaller 
than normal : breath cool, temperature of mouth 94° '2; it is difficult to conceive 
where the blood has receded to (private notes). The stomach was irritable, not re- 
taining liquids ; a few pink spots on the chest : e. t. 95° -4, p. 60, small but regular ; 
vomiting continues, no urine passed. Next day m. t. 97° "41 p- 76, vomiting ceased, 
no stool for four days, urine 14 ozs. in the last 12 hours, deep yellow colour, clear, 
acid, 1022, no albumen, chlorides ^ vol.: e. t. 97°"4, p. 70— thenceforward slow but 
continuous rallying, until another pronounced relapse set in, at the close of which the 
crisis was as marked and attended with delirium : convalescence fair. 

In contrast with these cases were a few others with equal or greater fall, yet even 
fewer signs of suffering : — M., 33. Crisis in the night with decline of t. 10° "2, p 60, 
yet pupils normal, the senses alert, muscular powers retained and mind only a little 
drowsy : next t. 95°*6, p. 64, r. 24, and no change, but the advent of pains in all the 
joints. M.. 28, a muscular subject, showed a fail of t. II° and of p. 72 in 16 hours 
(probably the t. was lower than 94° F.), and yet very slight inconvenience beyond 
depression. M., 22, was much distressed and very low at e. with t. 103°, p. 
120, r. 58 (? acme), the change nextm. being to t. 95°, p. 80, r. 50, shallow; and the 
state resembling that termed ' algid e,' yet no particular general symptoms. 



80 SPIRILLUM FEVER. 



Pseudo-crisis in the Relapse. 

Case XX. — M., 24, condition, an asthmatic subject : admitted apparently at 
critical fall of invasion-attack, some feverishness and bronchitis ensuing : on 7th day 
the relapse set in abruptly, and lasted other 7 days, ending abruptly with a fall of ff : 
during this attack the fever was well sustained until the 6th day, when a pseudo-crisis 
occurred, followed immediately by a return of fever, and next morning the true or 
final crisis. Although the t. was high (mean max. 105°) throughout and the p. quick, 
yet the man suffered but little distress ; there was some pulmonic and splenic con- 
gestion and pains in the limbs ; spirilla in the blood only indicated in fresh speci- 
mens, though distinctly seen in the prepared ones. 5th d. e. t. 105°, p. 150, no 
sweat or headache, slight thirst, tongue coated and moist, slight cough, spleen doubt- 
fully implicated, pains in the arms, calves, and knees, no stool, no eruption, he is 
weak : spirilla not quite so common as in the morning (at t. 103'' "6) and vary in size. 
6th day, m. t. 7 a.m. 97° "4 (i.e. a decline of 7° "6, and two hours later it was 96°, 
being a decline of 9°), p. 1 10, full, soft ; the fever left at 4 A.M., with much sweating; 
now the face is perspiring, no great depression, he can just stand upright, no distress, 
headache or thirst, tongue white and moist, slight cough, no sputum, spleen doubt- 
fully charged, has pains in the calves, one stool, no eruption : heart's action weak 
and second sound pronounced : it is stated that this cold, depressed state lasted until 
the sudden return of fever at 3 p.m. ; a few spirilla were founi of the usual aspect. E. t. 
I04°*6, p. 160, slight chills preceded this exacerbation, no headache, much thirst, gid- 
diness, some uneasiness in the chest and epigastrium, no splenic uneasiness, bronchitic 
cough returned, skin moist, intelligence good ; the spirillum is still present, though less 
easily found than in the morning ; the fever left in the night with much sweating ; 
m. t. 95°'6, p. 108, fair volume, regular; much depression yet no distress, the body 
seems shrunken, the mind clear, spleen felt ; not a trace of the spirillum could now 
be found in the blood, there were many pale cells, some being large and with a large 
nucleus : prompt and unchecked convalescence next ensued. 

Here by employment of the microscope I became aware that the fever had not 
ended with the first fall of temperature, although appearances were not unlike those 
of true crisis : in several other cases by the same means I was enabled to predict the 
end, whilst appearances were still of uncertain import. 

Premature and repeated Depression. 

Case XXI. — M , 30, was admitted at close of invasion-attack and quickly rallied. 
The relapse was distinct, defined and sustained for 4 days, the crisis being pi'olonged 
for 3 more : temperature till the acme almost steady at 102°, the pulse at only 100 : 
blood-spirilla many : there was much irritability of the stomach and also diarrhoea : 
last day of f ver m. t, 104° '2, p. 100 small, soft, regular, skin dry, no headache, 4 
stools passed with straining, frequent vomiting, tongue brown and dry, thirst, no 
sleep ; the blood contained numerous active spirilla and many white cells ; at this 
time, which seemed to be near the acme, the aspect of the patient was compared by 
me to that of incipient cholera, the dep ession being extreme, eyes sunken, and 
though the trunk was warm, yet the extremities felt cold : e. t. (axillary) I02°'4, p. 
108, skin diy, 5 stools, no more vomiting : he has rallied a little with the decline of 
temperature, yet the limbs are cold, pulse hardly perceptible and heart's sounds 
hardly audible, respirations 40 per min. shallow. What was this collapse in the 
midst of high fever owing to ? Cardiac debility was the most prominent feature 
(private notes). Next day the fall continuing m. t. 98° "4, p. 96, no sweats, but 
sudamina in axillae, 4 semi-fluid stools, urine free, hiccup has come on, eyes yellow, 
no eruption, some headache, thirst ; no spirillum in the blood ; the depression was not 
so marked, though the temperature had declined. E. t. (axillary) 98°, p. 98, very 
feeble, limbs cold, no stool since morning, vomited once, no sweats ; the man is in a 
state of collapse and remains so ; urine said to be scanty ; he denies having passed 
any for two days : the aspect is that of partial asphyxia. Next day, t. 97° "4, p. 96, 
skin dry, no stool ; hiccup continues, disturbing him at night, when he was somewhat 
delirious ; now he is at times sensible ; still no urine, bladder not distended, no 
urinous smell of breath ; some pain around the umbilicus: e. t. 95° '6, p. 83,no 



LYSIS. 8l 

sweats, or stool ; dry cups applied to the loins at lo a.m. and at i p.m. urine passed, 
25 ozs., pale ; tongue still dry and brown and irritability of stomach persists, with 
hiccup, the collapse is more marked, he yawns and stretches himself. Next day : 
m. t. 95° "2, p. 82, small, soft, regular: no stool or vomiting, delirium continues, and 
the prostration : pupils of normal size, no distress or dyspnoea and he takes a little 
food : urine plentiful, several ozs. being passed at a time, sp. gr. loio, pale, acid, no 
sediment, turbidity on heating not removed by nitric acid, chlorides diminished: e. t. 
95° -6, p. 84, skin dry, tongue brown in middle, white at sides and tip, moist, hiccup 
less, no delirium: next d. t. 96°-2, p. 80, the rallying was slow, no sweats ; three 
days later desquamation of the forehead was noted : the convalescence was eventually 
good. 

Lysis. — Subsidence of an uncomplicated spirillar attack at a slow 
rate, either continuous or interrupted, though rarely seen in Bombay, yet 
claims attention from the unusual severity of the cases exhibiting this 
mode of defervescence. The phenomenon is probably not so simple as 
might appear, and in this place I shall consider only the plainer in- 
stances, reserving the obscurer for the Chapter on Pathology. Judging 
from the clinical Charts, there are many forms intermediate between 
' crisis ' and ' lysis ' ; and, for convenience, I assume that when specific 
fever occupies not less than 2 days in its main decline, it may be said 
to subside by ' lysis ' ; usually the time so occupied is longer than this. 
The blood-spirillum is sometimes seen throughout ; at other times the 
organism disappears at the beginning of fall, not again to be visible in 
its subsequent course. Temperature and pulse at lysis are separately 
discussed. 

Frequency. — So many fresh attacks not being brought to hospital 
until near their end, I am unable to state definitely the proportion of 
lytic terminations ; amongst survivors about 10 per cent, and among 
casualties at least twice as many, of the cases displayed some degree of 
lysis. It was rarely seen in both invasion and /elapse, and very rarely 
in recurrences alone. A tendency to gradual defervescence either at 
beginning or at end alone of the main fall is not uncommonly seen, 
and it is usually accompanied with symptoms in some degree or kind 
severe. 

The lytic decline may be tolerably uniform, though interrupted by 
brief exacerbations ; sometimes it is remittent throughout : its whole 
depth is shorter than occurs in the critical fall, and I have only once 
seen a subsidence of 8° ; commonly the range is much less than this. 
Its duration varies from 3 or 4 days (the more frequent estimated length) 
to 5, 6 or 7 days : in the longer instances the date of reckoning may be 
arbitrary. How such attacks begin and their total duration have not 
been sufficiently ascertained, few patients being seen early enough : I 
know that an invasion may begin abruptly as usual, and its lytic decline 
be effected through depression of the latter half of the attack ; yet 
generally it was most probable there occurred an actual prolongation of 
the febrile state during this gradual defervescence. There may be a 
history of final perturbatio corresponding to the febrile acme, though 
usually not so. I have remarked that in these attacks febrile exacerba- 
tions preceded by chills, but not followed by much sweating, were not 
uncommonly mentioned as occurring throughout at night. In the in- 
stance of survivors, rallying at the end may be prompt as usual or only 
somewhat delayed. 



82 SPIRILLUM FEVER. 

The subjects were generally young adults ; occasionally the old : 
lysis seems proportionately rather most frequent in women, young and 
old : debility may be a predisposing influence ; Mussulmans were more 
numerous than Hindus ; and cases were seen chiefly after the height of 
the epidemic. 

Whilst there are no special symptoms attending fall by ' lysis,' yet 
debility and a tendency to prostration were invariable ; the typhoid 
state supervening much more frequently than usual : typhus characters 
were sometimes seen, yet not exclusively here. Headache was not ex- 
cessive, nor the splenic complication; epigastric (especially) and hepatic 
implication were common and marked ; jaundice, hiccup, vomiting, 
dysenteric diarrhoea, were not unusual ; febrile delirium was frequent ; 
sleeplessness, injection of the eyes, retention of urine, involuntary 
evacuations, hypersesthesia of the body or a sense of heat or formication 
have been noted : also giddiness, pains in the limbs, oedema of the feet, 
sore throat, cough, partial sweats : urine not particularly changed : the 
heart's action was invariably feeble, even when the pulse seemed full. 

As most patients recovered completely, though slowly, these symp- 
toms are referable to organic lesion which is transient. 

After invasion, the relapse may follow at intervals not exceeding the 
mean limits, and be either mild or severe, or it may terminate with death 
from incidental haemorrhage. Rebounds of temperature after deferves- 
cence by lysis, seldom occurred in uncomplicated cases. In survivors, 
definite complications were rare, though doubtless some of the func- 
tional or intercurrent lesions peculiar to spirillar infection, were more 
pronounced than usual — those of the liver and epigastrium (including 
stomach with left hepatic lobe and the semilunar ganglia ?) being par- 
ticularly indicated. 

Symptomatic fever may obviously interfere with critical fall, so as to 
induce a more gradual decline ; and that of pneumonia was best appa- 
rent in this connection. 

Diagnosis. — When the previous history of an attack is known, its 
mode of decline becomes matter of observation ; the presence of local 
complication might be suspected. 

Prognosis. — It seems to me remarkable that even a tendency to lysis 
should be usually accompanied by severe symptoms ; and I should 
anticipate that an attack characterised at its close with signs of prostra- 
tion and of abdominal lesion, would not terminate in prompt convales- 
cence : in 5 of 6 typhus-like cases lysis was indicated ; in 8 deaths from 
accidents subsequent to invasion-attack, 6 showed lysis at invasion ; and 
it seemed to me that, evident complications apart, whenever the typical 
crisis was departed from, the patient's sufferings were liable to be in- 
creased. 

Relapsing Fever : Decline by Lysis at Invasion-attack. 

Case XXII. — M., 49, condition fair, seized in hospital, admitted on 4th day of 
invasion : the fever is said to remit : there is much headache, eyes injected, general 
pains and tenderness of the whole body, with irritability of the stomach, some bron- 
chitis behind, considerable enlargement and tenderness of the liver, also tenderness 
of the spleen and epigastrium : urine scanty, high-coloured, acid, 1022, albumen a 
trace : m. t. 99°-8, p. 88 : e. t. i02°-6. Fifth day— m. t. ioi°-6, p. 96, tongue 
coated, moist ; acute hemicrania of r. side, muscular and arthritic pains : liver the 



CASES OF LYSIS. 83 

same ; bowels regular, vomiting in the night. Many active spirilla seen in the blood 
this day, as well as yesterday. E. r. 103°. Sixth day— m. t. ioi°-4, p. 112, weak, 
small, slight yellowness of eyes, no more vomiting, great tenderness with enlarg - 
ment of liver and spleen, skin dr}-, pains the same, one consistent bilious stool, slept 
a little (sedatives, local fomentation, quinine): e. t. lo2°-4, p. 116, liver still very 
tender, urine retained, 4J ozs. drawn, high-coloured, 1028, acid, no albumen. 
Seventh day — m. t. 98° -8, p. 96, weak, regular, urine 8 ozs., passed at night, high- 
coloured, 1020, acid, no sugar, no albumen, chlorides i vol., on standing a rather 
copious and very dark precipitate resembling blood but cleared by heating and the 
addition of liquor potassse (ammonia then evolved), and under microscope shown to 
be urates with much biliary matter, some masses being of the form of urinary casts : 
no uneasiness in the loins. Abdomen, including epigastrium, full and tender, skin 
dr)', tongue tending to drj-ness, two stools (after aperient) bilious ; there was some 
sweating last night. E. t. i02°-2, p. 120, fiiU ; no sweats in the day, epigastric un- 
easiness continues, urine 14 ozs., high-coloured, 1015, no sediment, no albumen, 
bile-acids and pigment present, no stool, tongue dry in centre, pains in r. shoulder 
considerable, injection of conjunctivse and oppression, but no headache. Eighth 
day — m. t. 97^, p. 80, full, weak. Urine 7 ozs. in the night, 1015, acid, amber 
tint, no albumen : epigastric uneasiness continues, no pain in r. shoulder, tongue 
moist, some sweating last evening, no headache, one stool, bilious, eyts yellow, 
slept a little, pains in hips, abdominal fulness less but tenderness not less, he is 
giddy and very weak. E. t. 98^-6, p. 88, feeble, one stool, urine free, skin moist, 
slight thirst, tongue white, furred, moist, no headache, giddiness continues. Ninth 
day — m. t. 95", p. 68, feeble, regular, tongue brown in middle, cold, great thirst, 
one scanty yellow stool, slept a little, general tenderness and puffiness of abdomen, 
the left lobe of the liver is enlarged, projecting in the epigastrium ; the patient is 
semi-collapsed and complains of drjmess of the mouth, no delirium or vomiting. E t. 
98^, p. 80, tongue brown, moist, one liquid highly bilious stool (after aperient), ten- 
derness and puffiness of abdomen continues, urine free, 1012, no albumen, chlorides 
J vol., bile-acids and pigments present : he has a slight headache and is still 
depressed : pains in r. shoulder and hips the same (warm applications to abdo- 
men, stimulants). Tenth day — m. t. 95° "6, p. 52, feeble, regular, tongue brown, 
moist, two highly bilious stools, much thirst, some sleep but now he rambles in his 
talk, much depressed, slight headache, pains all over, conjunctivae yellow and much 
injected, ner\'0us prostration ; no eruption now or previously. Urine free, 30 ozs. in 
the night, 1012, acid, no albumen, chlorides j vol., bile-acids and pigments present. 
E. t. 98°, p. 80, better volume, tongue the same, three liquid yellow stools, thirst, 
abdominal fulness and tenderness the same, general pains less, no headache. 
Eleventh day — t. 97° "2, p. 80, full, regular, tongue dryish and brown at the back, 
two stools, slept a little, pains less, jaundice more evident, urine 34 ozs., loio, no 
albumen, thirst continues. E. t. 99° '2, p. 96, three stools, thirst, no headache, 
abdominal uneasiness less, urine passed frequently in small quantities, tongue mo'st 
and clearing. Twelfth day — m. t. 98-', p. 84, feeble, tongue bro\\Tiish, dr}', one 
stool, much thirst, no headache, abdominal signs diminishing, pains in joints continue, 
slept, urine free. E. t. 99° '8, p. 100, feeble, tongue brown, moist, much thirst, 
no headache, drowsiness, abdominal uneasiness less, and so the pains in limbs. 
Thirteenth day — m. t. 99°, p. 100, soft, tongue clearing, much thirst, slight head- 
ache, drowsiness, urine free, abdomen easier, the liver still extends two inches lower 
than normal. E. t. 101°, p. 92, no headache, tongue clearing, epigastric fulness 
and tenderness said to have increased, the liver reaches ij in. below the costal 
margin, spleen not enlarged, urine passed with stools, slight scalding, pains in limbs 
and joints, the left eye is inflamed (ophthalmitis), no sweats, thirst slight, one scanty 
yellow stool. Fourteenth day — m. t. 98" '8, p. 88, no headache, tongue dry in 
dorsum, slept but little, slight thirst, one stool, urine free : thiere is still some un- 
easiness over the r. costal cartilages below, but less enlargement of the liver. E. t. 
98°, p. 88, no headache, free sweating during the day, slight thirst, bowels free, 
tongue moist, clean, abdomen easier. Fifteenth day — t. 98° -2, p. 80, no heaf^ache, 
eyes less inflamed, no uneasiness in the body generally : e. t. 98° -6. p. 72. Sixteenth 
day — m. t. 98° "6, p. 52, no headache, pain in sterno-clavicular joint, slight hepatic 
uneasiness, no more enlargement, spleen normal, bowels regular, urine free, eye im- 
proving : e. t. gS^-b, p. 80, feeble, regular. Seventeenth day— m. t. 98^-4, p. 84: 

G 2 



84 SPIRILLUM FEVER. 

e. t. 98° -6, p. 88. Eighteenth day— m. t. 98° -4, p. 80, slight cough with mucoid 
sputum : e. t. 99° "8, p. 88, full, regular, slight headache, skin warm, moist, slight 
tenderness over liver, abdomen rather full and tender, conjunctivae slightly injected 
and yellowish, no pains in joints, slight cough and thirst, tongue coated, moist. 
Blood examined, spirillum not found, though relapse had set in. 

Nineteenth day— m. t. 99°-6, p. 80, full, regular, no headache, skin dry, no pain 
in abdomen, or body generally, eyes yellowish, much thirst during the night, cough 
less, tongue clean, moist, bowels regular, urine free, appetite good, some giddiness : 
e. t. 103°, p. 100, full, regular, no headache or pains in the body, skin moist. 
Twentieth day — m. t. 102" -8, p. lOO, full, regular, urine free, bowels regular, appe- 
tite indifferent, there is tenderness and fulness of the abdomen and also of the liver 
and spleen, some pains in the joints of lower limbs, some thirst, skin dry, some 
headache, slight sweats during the night. Blood-spirilla present and active. E. t. 
I04°*6, p. 120, weak, slight headache, no pains in the joints, urine free, slight thirst, 
both liver and spleen are enlarged downwards, the abdomen is full and tender, con- 
junctiva; yellow, bowels regular, sweats in the afternoon, tongue coated, moist. 
Twenty-first day — m. t. 102° -2, p. 108, weak, slight headache, pain in loins, urine 
free, no stool, much thirst, nausea and hiccup during the night, no sleep ; eyes not 
redder, abdominal uneasiness the same, free perspiration at night, tongue coated, 
moist, skin soft, and moist over the head and upper half of trunk, no eruption, no 
shoulder pain or cough. E. t. io6°-4, p. 128, weak, regular ; headache severe and 
pain in back, no thirst, skin dry, tongue coated, inoist, abdominal uneasiness remains, 
slight cough, sweats on the forehead. Blood-spirillum not seen at this acme, 4 P.M. : 
5 t. 102° -6, 5-15 t. 100° -6, 6 t. 100° -4, 8 t. 99°. Twenty-second day — m. t. 
97° "6, p. 92, feeble, free sweats since last evening at 5, no headache or pains, is 
weak and giddy, no stool. E. t. 97°'4, p. 84, slight thirst, still some enlargement 
and tenderness of liver, spleen unaffected and abdomen free from uneasiness : sweats 
since i, vomiting, some jaundice, conjunctivae less injected, no pains in shoulder, has 
a tingling sensation in both arms and legs. Next day — m. t. 97° '4) P- 80, weak, 
no sleep, no sweats, is exhausted, liver and abdomen easier, slight pain in left 
shoulder : e. t. 98° -4, p. 88, giddiness and slight hepatic tenderness. A slight pain 
in epigastrium and some thirst on the following day ; and two days later he begged 
for leave. There was no recurrence of fever, and some weeks later he returned to 
duty in the medical ward, where he originally contracted infection. 

The chart of this case is copied in Plate V., No. 11 : the above narrative will 
serve also to illustrate some minor symptoms of fever attended with mild compli- 
cation. 

Lysis at Invasion with Cerebral Haemorrhage : Death. 

Case XXIII. — M., 55, famine-subject with bronzed, clammy skin, emitting a 
musty smell, depression extreme ; brought to hospital by wife and daughter, with 
fever of eight days' duration, e. t. 102" -4, p. 126, no headache, hepatic tenderness, 
no eruption ; for 4 days tlie fever then declined in a remitting mode to 96° '6, 
p. 88, no regular sweats throughout, no eruption, cough, thirst, vomiting, headache 
(diminishing), no delirium, slight jaundice, pains, tongue becoming dry and brown, 
a* the end he was very low but intelligent, no pains, skin soft, aspect peculiar, eyes 
yellowish, occasional hiccup, pulse weak but not small. Blood examined daily and 
spirilla seen until the last. A febrile reaction now set in with early typhoid symp- 
toms, oedema of the feet ; the t. rose gradually for 3 days to I04°"4, p. 120, when he 
became insensible, not comatose quite, and 2 days later he died : at autopsy cerebral 
haemorrhage with surrounding inflammation. No spirillar contamination during this 
secondary fever ; previously no symptoms of cerebral lesion, and other cases show 
such lesion not invariable in lysis. The man's wife had had fever ; the daughter 
(aged 8) underwent a pronounced relapse with copious epistaxis at the end, prompt 
rebound and death by thrombosis of femoral veins. 



HEADACHE. 85 



SPECIAL SYMPTOMS. 

I, Headache. — According to my personal experience the headache in 
spirillum fever seems not to differ in general character from that accom- 
panying malarious fever, or even non-febrile derangements : it is com- 
monly and chiefly frontal, sometimes extending to the temples ; seldom 
general and very rarely limited to the occiput : when temporo-occipital 
it may become blended with the pains in the nucha, so frequently 
present. 

It is perhaps the commonest of all symptoms, being practically 
invariable in some degree, at some period of the febrile attack ; whilst 
it is nearly equally absent during pre-febrile and post-febrile stages. It 
is, however, included amongst the occasional premonitory symptoms ; 
and if not it usually supervenes with the earliest rise of temperature, 
increasing as fever progresses and promptly subsiding with the crisis : in 
70 p. c. of invasion-attacks it was a prominent symptom, though less so 
amongst the weaver class, whose fever was of low type ; during the 
relapse, it recurs (as a prodrome occasionally) with other symptoms of 
fever, varying with them and not being so often prominent as before 
(50 p. c. of first relapses) : it again reappears with subsequent attacks. 
Patients described the feeling oftenest as 'great heaviness,' sometimes 
as 'splitting' or 'throbbing.' 

Varying lin intensity but usually very severe, and complained of 
especially as preventing sleep; its duration may be remarkably limited to 
that of the pyrexial state, and its severity also corresponding thereto, at 
remission (specially with sweats) and exacerbation, until the acme, when 
in some cases the headache was described as ceasing (no delirium) ; 
often, however, then becoming acute : with commencing decline of 
fever, the headache may at once subside : in some few cases, this symp- 
tom (like thirst and pains elsewhere) only slowly declines after the crisis; 
and as a rarity due to either idiosyncrasy or untruthfulness, it may be 
disallowed by a patient during the earlier days of his attack, coming on 
only towards its close, although the pyrexia and blood-state were pre- 
viously characteristic. Judging from their aspect, infants may have had 
this symptom (so also the ailing quadrumana); children complained of 
it, as well as adults : perhaps men suffered most; yet not the weak more 
than the strong, or v. v. 

In detail, correlated states were as follows : — the scalp offered no 
peculiarity, conjunctival injection and the state of the pupils no fixed 
relationship ; the foul, moist tongue oftener with pronounced headache 
than the dry-brown ; no definite concurrence with state of liver (or 
jaundice) or spleen, or epigastrium (or nausea, vomiting), or with consti- 
pation ; nor any with visible state of the blood. Its general connection 
with pyrexia was shown by the consentaneous remissions and exacerba- 
tions throughout : yet not its entire dependence, for it might (with other 
usual symptoms) be absent at first, or increase when pyrexia does not, 
and when this attains its acme, might temporarily or permanently di- 
minish and cease : lastly, in 8-10 p. c. of ordinary cases, headache only 



86 SPIRILLUM FEVER. 

gradually subsided in 2 or 3 days after crisis. Thirst, muscular and 
arthritic pains were the other closest, yet not invariable, attendants. 

In the severer attacks marked at the close by delirium, headache 
was usually severe, and it might cease just before the delirium came on 
(e. g. at acme), yet not seldom these two symptoms alternated, the 
delirium being present only at night : obviously it is impossible to ascer- 
tain with certainty their actual co-existence at any moment, and my 
impression was that the relationship here pointed to a common origin 
rather than to sequence or substitution. Several patients were admitted 
at acme with severe symptoms, who had had the actual cautery applied 
to temples or vertex of head, for relief of this symptom. 

Headache during secondary fever varied, being sometimes slight 
when pyrexia was high : and it was not a prominent character in fever 
symptomatic of local complications. 

As to its diagnostic import, its marked presence during the late 
epidemic certainly invited special attention in particular cases. A par- 
ticular point was the occasional occurrence of headache with hardly any 
other ordinary symptom about the date of an expected relapse, when it 
might be interpreted as a sign of suppressed or latent recurrence. 

Its prognostic value seems inconsiderable, my notes showing it to be 
less common or pronounced in cases dying both during and after in- 
vasion-attack, than amongst survivors at same periods : when death 
occurred from specific fever alone, headache was not, apparently, a pre- 
eminent symptom ; and it was subordinate amongst the signs of fatal 
complication. Its persistence after the fall usually accompanied the 
decline of fever by lysis, in cases often serious. 

There is no precise evidence of the anatomical conditions pertaining 
to this symptom. Probably cerebral congestion is present in many 
cases, such, e.g., as those relieved by free epistaxis, or by artificial deple- 
tives and derivatives : however occasioned, this head-symptom must be 
commonly functional in character. 

The cases quoted in detail above illustrate the often variable connection of head- 
ache with pyrexia and other signs : that of the woman, No. IX., shows the cessation 
of this symptom just before the critical perturbation. An adult male relative of hers 
declared its absence at the acme, with t. io5°'6, p. 132, sweating having begun. 
M., 22, on sixth day of invasion had a.m. t. I02"'4, p. 112, no sweats and much 
headache : p.m. t. 103° "8, p. 120, skin dry, no headache : next day (the last) a.m. 
t. i02^-8, p. 116, much headache, many spirilla ; P.M. t. I03°"6, p. 120, much head- 
ache, no spirillum present, and crisis following : at the relapse this symptom was late 
in appearing, and did not subside until the fall. M., 25, on last day but one of 
invasion, a.m. t. 102°, p. 106, much headache and sleeplessness from it ; p.m. 1.104°, 
p. 120, slight headache, with delirium following at night: last day a.m. t. I02°'4, 
p. no, much headache, and immediately after the critical perturbation and fall. 

From such instances I am unable to deduce any fixed relationships 
of headache with other symptoms ; the general connection has been 
stated, and in future enquiries the influence of any drugs administered 
would require to be eliminated. 1 have considered this point in the 
above remarks. 

2. Muscular, Arthritic, and Osseous Pains. — Though these make up 
one of the symptoms of a subjective character, not open to direct obser- 
vation, yet their reality was attested by many visible signs of distress. 



BODY-PAINS. 87 

They form part of a widely distributed series of perverted common sen- 
sations, and are here separately specified from their frequency and 
prominence in the spirillum fever. 

These pains are probably always present, and they were more or less 
complained of as severe, in upwards of 70 per cent, of ordinary cases at 
febrile stages : amongst fatal cases they were not more frequent. 

Not uncommonly aching pains in the limbs or trunk precede the 
onset of fever at a time when spirillar contamination may become 
visible : they promptly augment (or begin) with the pyrexia and increase 
during progress of the attack until the end, few cases being then free 
from pains ; in great part they cease or diminish with the critical fall, 
but may persist, and troublesome pains may even come on only after the 
crisis. It would seem they were finally rather commoner and more 
persistent during average first relapses and succeeding apyretic periods, 
than during the first attacks and apyretic intervals ; being marked in 
45 per cent, of cases at fall and 50 p. c. for the next few days amongst 
an ordinary series of relapses, as compared with 20 p. c. and 30 p. c 
respectively amongst ordinary invasions. 

Native patients referred these pains either generally or locally to 
muscles, fasciae, ligaments, joints and bones of trunk or limbs, alone or 
together : they were described as an aching, soreness, boring, gnawing, 
a sensation as if beaten, or not uncommonly as if the bones were 
being ' broken ' : the joints were highly sensitive, or stiff, or felt as if 
distended when there was no visible swelling. The loins and nape of 
neck (fleshy parts of the trunk), lower limbs, calves, thighs, knees, shin, 
femur ; seldomer the shoulders and elbows, deltoid, muscles of arm and 
fore-arm : less often wrists and ankles, and still more rarely the terminal 
structures of the extremities. In the less mobile bones and joints the 
pains might seem to be spontaneous, being however always increased 
by direct pressure ; generally in the muscles and smaller joints they 
were elicited only upon exertion and in proportion to the effort made. 
Sometimes their character was so acute as to keep the sick quiescent as 
if paralysed, and render them sleepless. The red muscles acting in- 
voluntarily for respiration and circulation may not have been the seat of 
such pains ; yet occasionally I thought the suffering evidently entailed 
by the act of coughing might be seated in the diaphragm and other ab- 
dominal muscles, and that the cardiac distress at high fever might be 
seated in the heart. Apparently febrile and non-febrile pains were 
alike in character. 

There were many degrees of severity, from the mild to an almost 
exquisite intensity. 

Commonly the pains appeared with the fever, augmenting and de- 
clming with the changes of pyrexia, subsiding at the crisis for good, or 
persisting 3 or 4 days longer, pains in joints being specially apt to 
linger ; sometimes they were more intermitting and attacked isolated 
parts in succession ; and occasionally they made their first appearance 
or were most intense, at deep critical stages. Whilst the trunk was 
seldom spared, the lower and upper limbs alone, or mostly, might be 
successively involved at invasion and relapse ; and the trunk during 
pyrexia, afterwards the limbs. 

Neither sex nor age seemed to be specially concerned : and the 



88 SPIRILLUM FEVER. 

weak, cachectic or emaciated seemed to suffer as much as the more 
robust generally, though I think the severest pains of all may have hap- 
pened to muscular subjects, some of whom on admission had cautery- 
marks along the spine (both sides) previously made to relieve these pains. 
Amongst Mussulman weavers in 1878, this symptom if not more pro- 
nounced was perhaps commonest and most lasting : their type of fever 
was 'low ' (see also the case detailed above. No. III.) 

So far as appeared, these pains were not essentially related to other 
particular symptoms, or state of blood or urine : nor to intensity of 
pyrexia, depth of fall or sequel : it was observable that whilst headache, 
thirst and special abdominal signs augmented at the acme of fever 
(during invasion chiefly) these pains did not appear so to increase: and at 
periods of exceeding critical prostration they might come on, temporarily, 
as delirium sometimes does. 

The diagnostic import of this symptom was sometimes obvious when 
patients presented themselves after the crisis of fever : here the previous 
history would guide with the general circumstances of the case, and also 
when scorbutic, syphilitic, malarious and rheumatic pains might be 
suspected ; visible local change, nocturnal exacerbations and diathesis- 
marks being absent in the uncomplicated spirillum-fever cases. 

The prognostic import was not strictly clear : their occurrence as 
prodromes is worth recollecting. 

It did not seem that coarse anatomical changes arose in parts the 
seat of pains, and as well the generally transitory duration of the symptom 
pointed to its functional character, or if organic to a highly localised lesion 
speedily compensated after fever. 

In my own case, first attack, there were some brief cutaneous red 
patches over the ankles and shoulders, where tenderness existed : no 
rheumatic diathesis. 

Occasionally an uncovered joint, as the wrist, the seat of pain, was 
found on measurement to be slightly swollen, but this without evident 
relationship to the symptom. 

Whilst the pains were often generally symmetrical, they were very 
seldom accurately so, and not rarely they were one-sided when most 
marked. Their seat at insertion of tendons of the patella was noted in 
case No. IX. 

Some varieties are here noted : — 

Pains only at Critical Prostration. 

Case XXIV. — M., 33, health fair, admitted on 5th day of invasion, had no pains 
in limbs at the acme (t. 104'' '2, p. 130), or at once with the extreme critical fall, t. at 
n ost 94°, p. 70, when a few pink spots appeared : the body-heat did not rise more 
than I ° for 24 or 30 hours, and for nearly another day only to 96°-6, p. 72, when 
general aching pains came on, and fresh eruption : on the third day after crisis m. t. 
98', p. 70, resp. 30, no headache or abdominal tenderness, extreme pain in shoulders, 
elbows, (most) wrists, knees and ankles, no pain in the loins, hips, or smaller 
joints of hands and feet : suffering limited to the joints, is increased on pressure and 
movements and so prevented sleep and incapacitates him forgetting out of bed: other- 
wise he does not seem particularly weak : the bones, muscles and skin of the limbs are 
not tender : the left wrist seems a little swollen : syphilis denied. Sedatives and 
liniment. Next day the pains were less in morning and had ceased at evening. 

M., 24, at end of Invasion jaundice and lytic decline, general aches and much 
hepatic tenderness ; 2 days later sudden nocturnal onset of pains and stiffness on right 
r.ide of body, so much limited as to suggest a hemiplegic character : no head- 
symptoms and in 3 days prompt convalescence. 



. THIRST. 89 

In a third muscular subject (M., 28) relapsing attack, the pains were not limited 
to the joints of the limbs, but implicated muscles and bones, and they greatly in- 
creased as the man began to rally after a sinking of the body-heat to 94° (possibly 
lower still) : in three days longer they had quite ceased. 

3. Thirst. — The craving for drinks (water being the beverage com- 
monly demanded by native patients) was practically invariable during 
fever; and although as a subjective symptom it was not open to precise 
recognition, yet the evidence of its urgency was sometimes so striking as 
to claim particular notice. • 

Beginning with or very soon after the advent of pyrexia, marked 
thirst increased with its progress, often being less with the brief mitiga- 
tion which precedes the acme of attack, then increasing again at acme, 
and subsiding promptly with the crisis in at least half the total instances. 
It was at least equally common in pronounced relapse as during first 
attacks, though not so urgent generally. After crisis thirst in some 
degree persisted not rarely, for two or three days. To the best of my 
knowledge, it was not a symptom premonitory of specific fever. 

Amongst modifications of character was the occasional dislike of 
native patients to cold water (iced water was seldom relished), which 
they fancied to excite chills, set the teeth on edge, or otherwise cause 
discomfort greater than relief, or apprehension of hurt : these fancies 
struck me as being possibly peculiar to the spirillum fever. At close of 
attack, thirst was often excessive ; having previously followed, tolerably 
regularly, the exacerbations and remissions of pyrexia. It was mani- 
fested at all ages and by both sexes : was not limited to the weak or 
strong, the starved or well-nourished, or to one period of the epidemic : 
it was most persistent, if not most intense, in the subjects of low type of 
fever. 

In the absence of controlling data, not much reliance could be 
placed upon the records of thirst as concurrent with many other symp- 
toms : its relationship to pyrexia seemed clear, yet occasionally this was 
contra-indicated, even decidedly, as for example at beginning of relapse, 
or near end of invasion, when the blood-contamination was invisible or 
slight and subsiding : I have, however, noted the absence of thirst with 
even copious presence of the spirillum — absence here doubtless meaning 
no urgent wish for water ; its concurrence with epigastric uneasiness or 
hiccup was not invariable ; it was usual after skin or nasal haemorrhage : 
and attended the defervescence by lysis, commonly also rebounds or 
secondary fever, and symptomatic pyrexias. 

The persistence of thirst after crisis may correspond to that of mus- 
cular or arthritic pains, and like them, it may even increase for a brief 
period at this stage : I could not trace a fixed ratio here of demand for 
drinks and copiousness of sweating or other drain of liquids from the 
blood, yet certainly the most copious imbibitions of water I saw were 
those of a man, after one or probably two relapses, and these apparently 
to satisfy a natural craving — as a consequence the urine was much 
diluted and weight of body nearly stationary, plenty of solid food being 
taken. 

Thirst, however, may persist at crisis without there being much 
sweating ; a dry feeling in the mouth being noted also, with no diarrhcea 
and the abdomen retracted. 



90 SPIRILLUM FEVER. 

This symptom had no prognostic value alone; in fatal cases it was 
usually pronounced, yet not more so than some other phenomena, and 
complications might be present. 

4. Appetite, — Though usually absent during fever, either a desire 
for solid food or sense of hunger might then be expressed by patients, 
who always had the means of gratifying their appetite, yet might be de- 
terred from doing so by inconvenient or unpleasant consequences. A 
curious distinction was occasionally made by the sick between the 
feeling of hunger and the immediate desire for food, there being a dis- 
inclination to eat from want of 'taste,' or wart of 'relish,' such as im- 
parted by salt (though this condiment was not wanting in the food) ; 
and it is likely some patients tried to eat in order to overcome the great 
debility and exhaustion experienced during fever. 

As a rule, however, appetite was wanting, and herein a great contrast 
to the frequency of thirst. In an early series of 30 selected cases, chiefly 
of famine-immigrants, this symptom was present and attracted attention 
in 3 during invasion -attack from 4-7 day, whilst fever was high, and 
vomiting, headache, pains and dry tongue prevailed : it was seldomer 
recorded amongst weavers with a low type of fever, or in the last series 
of attacks amongst town residents. 

I have noted the occurrence of good appetite near the end of a re- 
lapse, just before probable acme and sudden death by cerebral hsemor- 
rhage : yet it could not be said the symptom was common at any time in 
recurrent attacks. 

At the critical fall, the desire and capacity for food often returned 
as promptly as other signs of relief, and for some days the appetite 
might be excessive : striking examples of this kind were seen, and not 
rarely hearty feeding continued until the day (or possibly the hour) of 
relapse. 

Amongst the contingencies modifying recovery at crisis, want of 
appetite for a brief time was occasionally noted. 

Significant was the even ravenous appetite of some typhus-like cases, 
on cessation of fever : restriction of food had sometimes to be insisted 
on. The half-starved were not necessarily the greatest eaters. 

5. Vomiting. — During involuntary emesis glairy mucus and diluted 
bile of varied greenish hue was oftenest brought up ; when irritability 
of the stomach was excessive even water could not be retained, and 
frequently patients complaining of hunger would not take even semi-solid 
food lest epigastric uneasiness should follow : more rarely was there a 
little blood in the ejecta : occasionally liimbrici were passed : eructa- 
tions of gas were not common : milk previously swallowed came up 
curdled. 

Vomiting was more frequent in some classes of cases than others : 
thus, amongst hospital patients admitted late at invasion-attack it was not 
noted in more than 10 or 12 p. c, and at relapse not more than 20 p. c, 
of those surviving ; whilst in a series of 40 examples of contagion at the 
J. J. Hospital, seen mostly at early stages, it was noted in 75 p. c, and 
also in 6 of 8 other examples of contagion at the smaller hospital. 

It occurs in both abortive and relapsing forms of fever, and at re- 



VOMITING. 91 

lapses (even second) when marked, as often as at first attack : it may be 
seen at invasion only and exceptionally at a recurrence alone. Seldom 
mentioned as a premonitory symptom, it was noted from 3rd day on- 
wards, or as first appearing with the acme (not usual) or the fall (not 
unusual) : during relapses it seemed to come on later and persist longer, 
or till the acme : after both febrile events, it might still last 2 or 3 days ; 
its occurrence was not limited to one stage of the attack, coming on with 
fever it might continue 3 or 4 days, with acme it usually ceased and 
with the fall it might last for a time : it was noted oftenest at night and 
attended either exacerbation or remission of pyrexia. 

Vomiting in spirillum fever has the usual active character, and some- 
times was so frequent and urgent as to cause much distress and weak- 
ness : usually it recurred 2 or 3 times a day, being either spontaneous 
or produced by the ingestion of food. 

The most striking examples were seen amongst young men : infants 
might be free, and it was not common in females. 

It occurred to the well-nourished and well-to-do equally, at least, 
with paupers : at all periods of the epidemic, and in both sthenic and 
asthenic types of fever. 

It was not connected solely with degrees of pyrexia, or intensity of 
attack : nor was any fixed relationship evident with morbid conditions 
of liver, stomach or spleen ; and so far from corresponding with these 
localised changes, it did not invariably augment at acme or still less 
subside at fall : epigastric distension and tenderness might be present 
without vomiting or even nausea, whilst the act of vomiting might give 
rise to aggravated soreness. 

It was only occasionally seen in the rebound or secondary fever. 
Whilst noting this symptom in native patients, their habit of artifi- 
ciaUy irritating the fauces should be recollected ; and also the effects of 
incessant coughing. 

Vomiting cannot be said to bear distinct prognostic import : in any 
degree amongst fatal cases generally, it was rather less frequent than 
among survivors : that there might be copious stomachal hgemorrhage 
without it, was seen in a case quoted below. Its occurrence in certain 
cases and not in others almost precisely similar, could not be under- 
stood : in the severer instances of defervescence by lysis and in those of 
typhus biliosus the symptoms when present offered no peculiar indication. 
It was not observed in the inoculated quadrumana. 

Both symptoms and morbid anatomy indicate the possibility of con- 
gestion, small extravasations and probably of inflammation, as affecting 
the gastric and duodenal mucous membrane, which might be direct 
causes of vomiting : the excessive secretion of mucus andiriverted 
flow of bile co-operating. An indirect cause would be cerebral irritation, 
though I have not here ascertained this clinically. _ Mechanical con- 
ditions noted were over- distension of the stomach with water taken to 
quench excessive thirst, frequent action of the diaphragm, as in urgent 
cough ; and possibly the direct pressure or irritation of an enlarged 
spleen, or enlarged liver— the left lobe especially, might be concerned, yet 
I am bound to add no demonstration of this was gained. With unusual 
irritability of the stomach, mere change of posture might induce the re- 
currence of vomiting, as was well illustrated in the case of a native student. 



92 SPIRILLUM FEVER. 

It was not very unusual to note specks and small streaks of blood in 
the ejected mucus, and it appeared to me that such instances were transi- 
tional to the rare * black vomit ' proper. Some gastric haemorrhage was 
always a likely contingency, and may have been more frequent than 
reported ; vomiting being only an occasional sign of it. 

jNausea. — Not an infrequent symptom, either alone or preceding 
and alternating with vomiting : its local connection with state of stomach 
was not clear. 

6. Sweats. — A tendency to sweating contemporarily with remision of 
pyrexia, is as common in this specific fever as in that due to malaria ; 
and the peculiarly marked critical termination is attended with perspira- 
tion, more copious than in ague-fit. Both first and recurrent attacks end 
thus, and as a rule to which there are few exceptions, the skin becomes 
moist shortly before the temperature sensibly declines. In most cases 
the perspiration is so excessive that the clothes, and even bedding, 
become more or less saturated. A peculiar musty odour was occa- 
sionally perceived at this time, not apparently due to dirt : the sweat 
has a distinctly acid reaction in common cases : when collected {e.g. 
from the axilla) it was a clear liquid without sediment, always containing 
free granules or masses like micrococci and rods of bacillus or leptothrix, 
sometimes very long and slender ; once a monad with cilia was found : 
there was never seen a sign of the spirillum, even when the blood and 
saliva showed it. The cuticle may become macerated. 

Prior to the crisis, sweating occurs in the earlier remissions, espe- 
cially of the relapse ; also in the mid-fall sometimes seen, and in pseudo- 
crises of varying degree, which precede the perturbatio critica : sweats 
with fall of temperature may indicate the separation of specific and 
consecutive non-specific fever : they attend the post-critical paroxysms, 
also. Nine-tenths of crises are attended with copious sweats ; yet there 
is much variety here as to exact time, amount and duration of the 
cutaneous flux, and that irrespectively of temperature-changes. For 
one, two or three days after crisis, partial or nocturnal sweating is not 
uncommon ; but there is yet little accurate information on either sub- 
sidiary or main items of the phenomena in question : illustrations of the 
ordinary clinical records are given in the cases detailed above. The 
relationship of critical sweating to loss of body-weight has also been 
pointed out. When scanty, perspiration may be limited to root of neck, 
forehead, chest, axillae and groin, palms or soles : when copious it is 
general : both sexes and all ages are affected. It is probable that with 
visible perspiration the temperature of the surface is more or less re- 
duced ; yet it does not seem to be due to such reduction leading to a 
condensation of humidity ; and on the other hand, copious sweats are 
not the cause of loss of heat. It is even doubtful if there is any direct 
connection of mere sweating with fall of temperature ; for in seveial of 
my cases the disproportion of the two phenomena, in excess or de- 
ficiency, was very apparent, and the induction of copious artificial per- 
spiration did not lead to cutting short of fever. Copious sweating may 
be deferred until after crisis : but the possibility of partial transpirations 
at night being overlooked is obvious, and the skin may quickly dry. 



THE TONGUE. 93 

The prognostic import of this symptom is highly contingent, except- 
ing at the date when the invasion -attack usually ends ; and even then, 
the perturbatio critica may follow free sweating : here the state of the 
blood is the best guide. During relapses free sweating is common and 
more irregular. In fatal cases, sweating was hardly commoner than in 
survivors, excepting about the acme of invasion when casualties were 
commonest ; nor was it rarer than usual. 

7. Sudamirxa : Miliaria. — This eruption was commonest late in the 
epidemic, and amongst the weaker weavers and town residents : it may 
have been sometimes overlooked, owing to darkness of the skin, minute- 
ness of the vesicles and their limitation to covered parts of the body ; 
yet it was not nearly so frequent as to be characteristic. Nor when 
even abundant, was it always associated with particular symptoms, 
severity or stage of the fever ; and though commonest at the crisis 
(without any definite relation to copiousness of sweating), yet it has been 
noticed so early as the first day of a relapse. Perhaps the most abun- 
dant crop of miliaria I saw, which covered all the front of the trunk 
and extended on the upper limbs, occurred at the close of a brief 
specific relapse of two days, intercalated between invasion-attack and 
relapse proper : there had been no such crop at the first great crisis, 
and in the succeeding event there was but a scanty one. In some of 
the most pronounced critical phenomena, sudamina were absent \ and 
on the other hand scattered vesicles might be seen in the slight or partial 
sweats occurring while fever persisted. The site also varied ; usually 
when few, the vesicles were seen at the root of the neck, or on front of 
trunk ; when numerous, they congregated chiefly on front of abdomen, 
or chest, in the axillse and groins; less on front and inner aspect of arms 
and thighs, the flexures, and on outer side of fore-arm, back of hand ; 
about the knees and upper part of the legs : the crop was unusually 
symmetrical and sometimes seemed to follow lines (? nerves) on the 
limbs. The size of the vesicles varied from a pin's point to a split pea ; 
their contents generally clear, rarely opalescent (without severity of 
symptoms) or sanguineous : their duration varied from a day or two, to 
a fortnight ; successive crops might appear : when dessicated no sign 
was left, or a branny exuvium, seldom a more defined desquamation of 
the cuticle in flakes ; but once the skin was stained over the site of the 
vesicles, of a petechial tint. 

I think this eruption was more frequent in spirillum fever than in 
others at Bombay, yet it was not limited to this; and it had not, therefore, 
a true diagnostic import : its prognostic value, also, was not apparent. 

From the fact of sudamina usually appearing with sweats and in 
similar localities, it may be presumed that a physical connection existed 
between these symptoms. 

This sign was placed in my list of ' complications,' but its natural 
connection with cutaneous perspiration induces me to consider it in this 
place. 

8. The Tongue. — The aspect of this accessible internal organ has 
the same significance here as in other fevers, with reference to state of 
the circulation, respiration, digestion and innervation, and the general 



94 SPIRILLUM FEVER. 

nutrition. As p3Texia progresses, the effects of increased vascularity, 
and of gradual inspissation upon its surface (where broadest and least 
mobile) of the buccal fluids, leading to change of colour from white to 
brown, become evident to the physician ; and the special function and 
movements of the organ may also become impaired. Usually the dry, 
brown fur is seen only at the back or down the middle of the tongue, 
then a white creamy layer, and at the edges a florid, moist aspect : occa- 
sionally the organ is flabby and indented by the teeth at its sides ; 
sometimes (in young persons) it acquired a ' strawberry ' aspect ; and (in 
old or thin subjects) with low fever it became shrunk, fissured, blood- 
stained and motionless. At the height of the epidemic, I frequently 
noted a triangular clear space in front of the coated surface, which was 
found to be due to voluntary or involuntary scraping of this part by the 
upper incisor and canine teeth. Other incidental circumstances in- 
fluencing the aspect of the tongue were an under-hung jaw, prominent 
upper incisors, a habit of sleeping with the mouth open, all conditions 
precluding free breathing through the nares only ; the ingestion of pul- 
taceous food : during fever (when thirst becomes considerable) the 
frequent drinking of water. Some native patients would attempt as 
usual to clean their tongues mechanically, at early morning before the 
surgeon's visit ; and others indulged as long as possible in the use of 
customary sialogogues (whence a deep red hue), both women and men 
doing this : not seldom in dark subjects, the tongue is naturally pig- 
mented at its sides. 

In the general clinical description, with illustrative cases, the tongue- 
changes at different stages of the fever have been described, and varia- 
tions here are no more than usual. Owing to great elevation of pyrexia 
and quickened breathing these changes supervene promptly, subsiding 
at crisis with other symptoms : in about 50 per cent, of ordinary first 
attacks the tongue becomes dry towards the last day, and in about 30 
p. c, of relapses : at the acme of fever, it was dry in at least 70 p. c. and 
50 p. c. respectively ; and at the crisis, in about 40 and 30 p. c. respect- 
ively : an organ drying for more than a day acquires a brownish hue, 
which may persist a short time after dryness ceases : thirst and the dry 
tongue here go together, but thirst tends to last longest. The state of the 
tongue was seen to correspond even closely with that of the skin during 
both remission and exacerbation of fever; their dry and moist conditions 
appearing simultaneously and even quickly interchanging : hence the 
condition of the tongue may vary from morning to evening of the same 
day, until near or quite the end of fever. 

During defervescence by lysis, although the temperature is declining 
the state of the tongue does not necessarily improve, but the reverse, until 
fever ceases: and after even a critical fall, with its prompt general amend- 
ments, I have not rarely seen the tongue still dry and brown for :? or 3 
days longer, there being then a want of systemic reaction or some 
local complication ; considerable variation may be noted at this time. 
Pallor of the tongue, as of other parts of the face, attends the crisis ; 
when it occurs during pyrexia and especially at acme, it partakes of a 
general significance. 

After defervescence, the tongue-changes subside gradually as they 
supervened, the middle and back i)art of the dorsum both earliest and 



STATE OF BOWELS. 95 

latest showing the dry and discoloured aspect : by the 3rd or 4th day of 
first apyretic interval the organ has nearly or quite resumed its normal 
appearance. When febrile complications now occur, the state of the 
tongue corresponds. 

During recurrent attacks, the tongue may become dryish on the first 
evening and thinly coated, red and thickly coated the next day, and 
possibly dry and brownish in the centre on the third : the dorsum may 
then become glazed towards the front : a mitigation may be noted here, 
as during invasion, just before the acme ; at the crisis, reversion to the 
normal state is prompt. For some time, however, in this second 
apyretic interval a smooth and glazed aspect of the tongue may persist, 
in patches or continuously over the dorsum, which seemed to arise from 
atrophy more or less marked of the papillary surface, with subsequent 
imperfect production of epithelium ; such wasting corresponding to 
the general emaciation so usual after two (or even one) pronounced 
attacks of spirillum fever ; the tongue also is ansemic, and for a time 
dryish. In such instances the appetite may be vigorous, and no com- 
plaint was made of the loss of the special sense of taste. 

In typhus biliosus and low types of fever generally, the tongue was 
apt to acquire the aspects well known in the more prolonged continuous 
fevers of Europe ; and the florid, parched and contracted state often 
persisted after crisis. 

Febrile delirium or dysentery are not associated with a particular 
state of the tongue alone; nor is vomiting or other sign of the epigastric 
disturbance so common in this fever. 

The movements of the tongue did not commonly attract attention 
in spirillum fever ; their significance being borne in mind. 

Glossitis was not seen as a sequel : mercury was rarely given in these 
cases. 

9. State of the Bowels. — It was seldom that the alvine functions 
remained undisturbed throughout, constipation at some time being the 
rule ; sometimes irregularity of the bowels, with diarrhoea, and at the 
crisis there may be seen a mild kind of dysentery. Blood in the stools 
was rare : the presence of lumbrici was not commoner than in other 
diseases of natives. Severe and fatal cases were often attended with 
involuntary alvine evacuations, at the advanced stages of fever ; and at 
the same time prolapsus ani might be seen. 

Special attention could not be given to this subject in a native 
hospital, but some illustrations of ordinary experience will be found in 
the detailed cases ; and upon analysis of others, the following remarks 
are founded. 

Constipation. — The alvine evacuations may be scanty or suppressed 
for a few days before the onset of primary fever ; there was seldom con- 
stipation before the recurrences. During invasion-attack the bowels 
were decidedly costive in about ^ of the cases, and sometimes remark- 
ably so, the patient declaring there had been no stool for 6, 8, or 10 
days : at the acme constipation was noted in 70 p. c. and at the fall in 
50 p. c. of common cases ; with these final stages in debilitated sub- 
jects, old or young, the stools were sometimes passed in bed : torpidity 
of the intestines may continue for a short time after the crisis. During 



g6 SPIRILLUM FEVER. 

first relapse constipation was not so frequent, and seemed to come on 
later ; it was decided in 25 p. c. of cases at acme and 30 p. c. at fall : 
involuntary evacuations were perhaps commoner now, at the end, than 
in the first attack, whenever the relapse was pronounced. Subsequent 
recurrences were not peculiarly distinguished. This symptom was not 
apparently associated with unusual implication of the liver, and it 
might be present in the absence of jaundice ; yet it was usually pro- 
nounced in cases of typhus biliosus (uncomplicated) : it is to be noted 
also that pauper patients had often not tasted food for some time before 
their admission, that irritability of stomach might interfere with feeding, 
and that sometimes the whole muscular system was evidently debili- 
tated, the secretions generally being scanty as well. In severe and 
fatal cases there was a great tendency to irregularity of the bowels, and 
finally to diarrhoea rather than to constipation. 

With costiveness the stools were not excessively hard, white or foul ; 
though scanty, the tendency was to diminished consistence, and I was 
often struck with the evidence of abundant bile when it might be sup- 
posed the liver was unusually implicated : the stools may be darker 
than usual. 

10. Diarrhoea. — Was rare prior to the close of febrile attacks, in a 
series of 40 cases being noted only once so early as 6th day of invasion, 
in a lad of fifteen, when there was marked general abdominal tenderness 
without fulness, and cessation of the diarrhoea spontaneously at the 
crisis : similarly prior to costiveness and pale stools at acme and fall, 
there was diarrhoea, probably bilious, in the woman whose case is de- 
tailed as No. IX. 

As the result of constipation, over-indulgence of appetite, lumbrici, 
drugs, bilious derangement, chill, or irritability of the enteric mucous 
membrane, this symptom may at any time supervene, the stomach also 
sometimes becoming irritable : its connection with congestion or in- 
flammation of the same lining membrane (found not rarely at autopsy) 
is also intelligible : it occurred in the lad referred to above after the 
crisis, when such congestion was strongly suspected to exist, the tem- 
perature rising a little (99°) and pulse : see also the case H. A., No. X., 
where the post-critical flux tended to become dysenteric, as was by no 
means an unusual occurrence. 

In cases fatal near end of invasion real or apparent, diarrhoea is apt 
to supervene after the 5th day, the stools being passed in bed : in cases 
dying later, the bowels were often irregular, and similar sign of debility 
not uncommon from the first. 

The aspect of diarrhoeic stools varied ; bile was usually indicated in 
plenty, and the transitions towards the mucoid and variegated evacua- 
tions of dysentery were not uncommon amongst native patients : stools 
passed in bed could seldom be inspected, and I would add that the 
diagnosis of unusual flux in these instances of paralysed sphincter 
might be fallacious, owing to constant dribbling of the faeces. 

Abdominal distension, flatulence, meteorismus, were not usual in 
connection with diarrhoea; but rather a collapsed state of the parietes : 
tenderness was usual, though not limited to the region where the ileum 
ends. Right iliac gurgling was decidedly rare throughout the epidemic, 



DIARRHCEA. 97 

even when the stools were liquid and yellow, and pink spots were pre- 
sent similar to those of typhoid fever : yet the results of autopsy clearly 
indicate the possibility of enteritis localised as in typhoid, though with- 
out ulceration of the Peyerian glands. Hypogastric uneasiness with 
diarrhoea was sometimes noted. 

The varieties of this symptom were several, yet rarely of marked 
character ; the wholly critical diarrhoea being very unusual, and though 
it were indicated a few times, yet not fully, or to the exclusion of cuta- 
neous flux: an instance is quoted below. Under the head of 'Com- 
plications ' some other remarks are added. 

Blood in the stools was rare ; it may have been overlooked, but on 
the other hand might be confounded with black bile in the stools (the 
point was borne in mind) : it was a critical or post-critical phenomenon. 

Diarrhoea at Crisis of Fever. 

Case XXV. — M., 15, admitted with his fa' her (case of typhus icterodes) at close of 
invasion-attack, which ended by critical decline of 7^ '6, sweating probably scanty, 
constipation of *^he bowels ; an eruption of pink spots, depression, abdominal tender- 
ness not mentioned. The relapse was very pronounced and produced much suffering: 
on the 4th and last day, m. t. I04°"4, p. 1 12, severe pains in the limbs preventing 
sleep, tongue coated, much thirst, disinclination for food and has eaten hardly any- 
thing of late : aspect dusky and depressed, no debrium, there is much general ab- 
dominal tenderness on pressure, bowels free, spleen now to be felt. E. t. 104°, 
p. no, resp. 32, pains in loins and knees severe, much thirst, spleen larger and 
tender : the blood still contains spirilla, and also some free protoplasm and large 
granule-cells. Next day — m. t. ioi°-4, p. 100, had no sleep in consequence of being 
frequently purged, motions watery ; the splenic and abdominal tenderness continue, 
no sweating, no eruption ; the diarrhoea ceased of itself with this slight decline of 
t. ; much debility. At noon t. 99° '4. E. t. 96° "2, p. 66, no sweats, splenic uneasi- 
ness and fulness less, one stool. The body-heat still remained low — next d. m. t. 
96°, p. 64, no sweats, again diarrhoea, motions scanty and watery ; there is a sense 
of abdominal distension but no such distension is visi hie, nor is there any evident tender- 
ness or enlargement of the viscera, much thirst, a few pink spots have appeared ; the 
lad is so exhausted by the purging that he cannot walk. Depression continued this day: 
on the following day m. t. 97°, no more purging, now pains in the joints, some sore 
throat, some uneasiness on pressure near the umbilicus, no splenic uneasiness : after 
a rise to 98°, the t. again declined next day to 96° -4, p. 66, and there was still 
general uneasiness of the abdomen, without fulnes=, no more eruption, no jaundice : 
after this date reaction began, the appetite became excessive, the local signs subsided, 
the spleen being nearly imperceptible, bowels regular. It was my impression that 
the diarrhoea was connected with the acme and crisis of this attack, being probably 
a tended with congestion {? petechise) of the enteric mucous membrane, which is 
known to occur in severe attacks of fever at their close : it was not apparently due to 
cold or indigestion. 

Melirna. — M., 25, famine-immigrant, weak, admitted near close of invasion, two 
remitting paroxysms being seen, last temp. i02°-8, p. 126, tongue coated and florid, 
a burning sensation in the soles and palms, hepatic and splenic eni rgement, 
and decided enlargement of the spleen: at beginning of fall t. 9S°"2, p. 'io (next 
morning 96°, p. 80), blood appeared in the stools which soon were passed in bed ; 
sweating doubtful ; the bowels became relaxed and stools dysenteric, and then bilious: 
perspiration followed the defervescence, the tongue being white and dry : recovery 
was prompt : no relapse. 

Another instance was that of a vernacular student (severe attack, relapsing), who 
had also epistaxis and may have swallowed blood, there was vomiting and decided 
hepatic implication, but less splenic. 

II. Circulating System. — The Heart .— A\mos,\. the only changes 
noted at autopsy of fatal cases, were distension of the right cavities and 

H 



98 SPIRILLUM FEVER. 

left auricle, with a pallid aspect of the heart-muscle at late periods of 
fever especially. The absence of more manifest lesion in even severest 
cases, renders it probable that in the milder surviving the heart does not 
greatly suffer ; and such inference is supported by the prompt rallying 
and complete convalescence, usually witnessed. Marked functional 
derangement, however, attends the specific fever ; presenting certain 
invariable and some occasional features, which in their combinations 
may be peculiar to the spirillar infection. 

Derangements noted. — Weakened impulse ; first sound weakened, 
prolonged, attended with a basic murmur ; dilatation of right side of 
heart, and changes in position. 

Relationship to stage of disease. — The condition prior to pyrexia of 
invasion was unknown ; with fever derangement begins, and pari 
passu augments to the end ; after crisis, debility persists for a time : 
with relapse the same series of symptoms is repeated, and at pronounced 
recurrences may be more apparent than at invasion. 

Frequency. — Feebleness of .the heart was, according to my observa- 
tion, invariable, statistical data regarding the other clinical signs are 
wanting, the following remarks being derived from a few, unselected cases 
specially watched : age of the subject, as well as comparative severity of 
attacks, might account for variations noted. 

Examples. — Symptoms in a lad of 14: Chart 2, Plate IV. At the beginning 
of invasion-crisis the heart's action seemed forcible, yet the second sound decidedly 
predominated ; p. 142 ; the blood contained no spirilla, but large clumps of granular 
protoplasm. During first apyretic interval, slow restoration of the heart {^ide pulse- 
rate), action regular ; second sound predominant. With onset of relapse, 2nd sound 
still accentuated, the first had a ' booming ' character at apex of heart, most distinct 
in the recumbent posture (direct comparison was here made with another lad free 
from fever) : in the evening both temp, and pulse had risen, heart's impulse felt 
inside 1. nipple, first sound booming and prolonged, with a decided bruit over a space 
limited to base of heart and best heard at junction of 4th left cost. cart, with sternum; 
where systolic sound predominates, at apex downwards, and upwards along aorta it 
is less pronounced than the diastolic, and its booming character becomes lost ; also 
beyond the cardiac area. On placing the patient in sitting posture, a diminution of 
the booming and bruit ; the prolonged character of first sound more diffused, its 
bruit slightly transmitted along the aorta : impulse not more apparent, felt lower 
down than when in lying posture. The pulse was unusually rapid in this case ; 
tolerably full and firm. Second day — temp, and p. reduced : the first sound less 
booming ; bruit fainter, heard in recumbent posture at base, not in sitting posture ; 
impulse distinct ; second sound more accentuated. In the evening, temp, and pulse 
risen : some general distress ; the systolic bruit is best heard above left nipple and 
towards left clavicle, as if produced chiefly at orifice of pulmonary artery : heard also 
in sitting posture, but it varies in character and intensity ; it is rough in tone : over 
the carotids a bruit is heard on application of stethoscope. Third day— still high 
fever, pulse now soft : aspect distressed : systolic bruit as yesterday, very local and 
best heard in lying posture : in the evening, acme of fever, pulse 130, again firm ; 
the bruit is very distinct at base of heart, where there is visible a broad pulsating 
wave, not felt by the touch, which I attributed to the action of distended auricles; the 
bruit does not travel downwards and to the right and therefore is not produced by the 
tricuspid valve, it is heard in the sitting posture nearly as well as in the recumbent : 
heart's impulse as before, practically absent ; second sound predominant : spirilla in 
blood declining, white cells and large protoplasmic masses abundant. Last day — 
fall in progress, p. 120, less full and softer, thrilling, not dicrotic : bruit not now 
heard in any posture, first sound rather booming, no perceptible impulse, second 
sound predominates. In the evening, p. 80, irritable, small, weak, intermitting at 
30-60 beats : heart's action wea''er, first sounfl booming in sitting posture only ; the 
second more accentuated ; impulse barely felt. 



THE HEART. 99 

First day of second apy relic interval : t. 96° "6, p, 76, smaller, weaker, but 
regular : first sound has the same character ; impulse none. Second day — still de- 
pression, p. 70 lying, 100 standing, weak, small, faltering : heart's sounds— lying 
posture, the booming character less pronounced ; action of heart faltering, excitable, 
slightly irregular, the diastolic pause decidedly prolonged, and hence an impression 
of slowness although the beats are 70 per minute : sitting posture — action quickened, 
first sound becomes so brief as to be almost inaudible and the deliberate character is 
lost ; second sound greatly predominant : standing posture — temp rary reversion to 
the comparative loudness of first sound, not now booming, but simply stimulated by 
change of position : the second sound at first subsidiary, becomes predominant as the 
effects of muscular exertion decline : impulse and auricular wave absent. For ten 
days longer, the heart's action had the same character of abbreviated and approxi- 
mated sounds, and prolongation of the pause ; first sound faint and impulse slow to 
return (slightly fell on 7th day) : on the i6th day, the normal state seemed to be 
restored. 

To my apprehension the above phenomena were referable to the varying state of 
the blood, and to the impaired nutrition of the heart-muscle ; the cardiac valvular 
apparatus not being structurally concerned. 

In the instance of two adults, one of whose cases is detailed above as No. IX. , 
I observed at acme of invasion signs of dilitation of the right side of the heart, in 
augmented cardiac dullness and extension of impulse to the ensiform cartilage and 
beyond towards the right. One case also revealed a first sound booming but free from 
murmur, over the cardiac region : at the base, second sound alone heard and along 
the aorta, chiefly, it was attended with a roughness, as if from friction. Crisis next 
morning — the labouring impulse had disappeared, first sound fainter and less rum- 
bling, second sound more predominant ; p. loo, very weak : during the ensuing 
apyretic interval, the impulse did not return till the third day, and then there was 
noted a slight reverberation of the first sound along the aorta (?). With a brief 
specific relapse, I noted that the first sound was attended with a soft murmur, heard 
best to the right of the ensiform cartilage, and over the mid-cardiac region it had a 
slightly booming character ; these features subsided at the crisis. 

As an example of changes in fatal cases, I quote the case of a lad, set. 10 ; just 
prior to the acme, when the blood was charged with spirilla and large granule-masses, 
p. 100, soft, the systole of the heart appeared forcible and tumultuous, and the first 
sound so altered as raise the suspicion of pericarditis ; yet these characters passed 
away with the crisis : lobular pneumonic collapse ensued, with fatal exhaustion, and 
after death the heart was healthy-looking. In another case at acme of invasion, 
p. 96, soft, it was noted that the heart's action was tumultuous, the face congested 
and there was throbbing of the carotid and temporal arteries : at autopsy muscular 
substance pale and soft ; pneumonia on the left side. 

In general, during fever a weakened impulse was always present, 
progressing with the pyrexia (at exacerbations increasing and v. v.) until 
the crisis, when the heart's action promptly declined on cessation of the 
febrile stimulus, and but slowly afterwards regained, like other muscles, 
its normal tone. The conjunction of rapid action with debility, a pro- 
longed booming sound, a full, soft pulse and blood charged with quasi- 
foreign particles, is probably characteristic. 

The weakened first sound was a necessary corollary : at crisis it 
may be inaudible, and almost so for a few days longer, when depression 
is prolonged ; most patients on their discharge, had still the feebly acting 
heart. 

Alterations of first sound. — The booming or prolonged character was 
very frequent : it was limited to the cardiac area, almost ceasing at the 
base of the heart opposite the 3rd or 4th costal cartilage ; its seat is the 
thicker cardiac muscle, and it may exist alone. The systolic murmur is 
less frequent and seems to differ in its seat at arterial or venous orifices of 
the heart (see above): though often attending the booming sound, it is not 



lOO SriRILLUM FEVER 

to be confounded with it. Undoubtedly simple ansemic murmurs were 
present in fever patients, yet they are not identical with the above. 

Diastolic changes. — Accentuation of the second sound necessarily 
following partial suppression of the first, its early occurrence in spirillar 
pyrexia is noteworthy : whether or not the valvular sound is ever modi- 
fied, except in partaking of a general debility, remains uncertain ; it 
may be widely diffused over the cardiac area, as well as predominant. 

Altered relationship of sounds and pause. — For a few days after 
crisis with a pulse quicker than normal, cardiac action may be of brief 
duration as well as of enfeebled force, the succeeding diastolic interval 
then being prolonged : rhythm is apt to be irregular, and irritability of 
the cardiac muscle marked. Such a hesitating and quasi-spasmodic action 
was noted with a declining pulse, fourteen days after relapse. 

Change of volume. — As estimated by area of cardiac dullness on 
percussion, this may be obscured by varying volume of the lungs, 
(especially on left side) or of liver, stomach and spleen. In the three 
cases detailed, I considered that at the acme of fever there occurred 
distension and consequent enlargement of the right side of the heart, 
and also of the left auricle. 

Change of position. — I found distinctly that the heart was, at acme, 
displaced downwards and to the right, by conjoined pulmonic (left lung) 
and splenic encroachment, returning promptly to its normal position 
when pyrexia ceased. I have also noted the organ to be displaced 
backwards and upwards, so lonor as high fever existed, by distended 
stomach and intestines, and enlarged liver. Much variety obtains here, 
yet in extreme and even fatal cases, it did not seem that displacement 
alone led to interrupted or irregular rhythm of the heart's action. 

12. The Pulse. Frequency. — Whilst following the temperature, the 
pulse tends to lag behind ; and this tendency becomes more apparent 
with successive relapses : it is visible even at the close of the invasion- 
attack. Such data indicate that under the continued and repeated 
stimulus of high spirillar pyrexia, the irritability of the pulse becomes 
more and more slowly manifested. At the same time, when the sti- 
mulus is withdrawn, the pulse but gradually reverts to its normal state ; 
after each febrile attack, it for a time descends below the normal 
level, the disposition thus to decline varying in different cases. Refer- 
ence should here be made to the chapter on Pyrexia. 

Excitability. — This feature is seen at end of crisis and during apy- 
retic intervals : in some instances the pulse increased 20 to 30 beats, or 
more per minute, on the patient changing posture from the lying to 
the sitting and standing : this effect of muscular exertion does not last 
long. When during febrile or incidental stimulus the pulse rises in fre- 
quency, it may become bounding or thrilling, functional irregularities of 
rhythm often disappearing for a time. 

Volume. — During high fever, especially for the first few days, it may 
be tolerably full or large ; this state tends to diminish, and at crisis the 
volume is greatly reduced : subsequently it is moderate. 

Strength. — A hard or incompressible pulse must have been very 
rare in unfomplicated cases of spirillum fever, for I do not recollect 
meeting with an instance : to the touch the feeling was always of easy 



THE PULSE. lOI 

compressibility, and I am aware this test is not always a sure one. At 
the crisis feebleness, and subsequently softness of the pulse. In some 
fatal cases a firm pulse has been noted : e.g. female adult, at probable 
acme t 105° -6, p. 140, full, strong and incompressible, was recorded : 
there was cerebral haemorrhage, congestion of scalp, firm contraction of 
left ventricle, kidnies pale, not enlarged ; the blood contained large 
granule-cells. Granular kidnies were very rare in native fever-patients 
at Bombay. 

In the course of the chief stages of fever, crisis and apyrexia, sudden 
changes of the pulse (other than in frequency) were rare. According 
to my experience, dicrotism during fever was hardly ever seen ; at the 
most a tendency to redoubling of the beat being noted in a few instances 
at acme, or during a pseudo-crisis : such cases amounting to four or 
five only. Intermittency was occasionally noted at the crisis. 

So far as the pulse depends on the action of the heart, a close rela- 
tion was observable throughout : so far as it pertains to the arterial 
system, the pulse, as felt by touch at the wrist, indicated diminished 
tension : possibly some fallacy lurked here, yet this was my own im- 
pression, and allowance is made for occasional rigidity from arterial 
disease. 

Sphygmograph Tracings. — Those appended are enlarged copies of 
originals taken at the J. J. Hospital during 1878, with an ordinary 
Marey's instrument (always radial) : other series are ccncordant. Nos. 
I to 8 pertain to M., 35, admitted at close of invasion : i to 3 are 
successive tracings on last three days of spirillum fever, they indicate 
pyrexia with excitement as at early stage of typhus, but differ in the 
blunter or more rounded end of the pulse wave. No. 4 is at crisis : the 
wave though much depressed, still shows signs of intra-vascular pressure. 
Nos. 5, 6 and 7 are days succeeding crisis, the indications of obstruction 
to blood-flow, becoming more decided ; they are afterwards less ap- 
parent : No. 9 is from another case, at i8th day after last relapse, it 
probably corresponds to the infrequent and excitable kind of pulse 
alluded to above. Nos. 10 and 11 were taken just after acme of inva- 
sion, and two days later during a febrile rebound (v. Chart 3, PI. IV. 
and Case X.) : they are similar, and they differ from specific fever 
tracings. The series of tracings from this case shows that with onset of 
first relapse, the pulse resumes its character at invasion, and maintains 
it more manifestly on successive days : vide No. 12 : the tracing at 
crisis is also alike, although the temp, had not declined below 99° '8, 
and for 6 days longer there were indications of augmented blood-pres- 
sure. At the brief second relapse, on the first day the tracing is that of 
specific fever ; on the second (at probable acme) it is different, indicating 
a much less obstructed blood-flow : normal characters were reappear- 
ing when the man left hospital, three weeks afterwards. 

Fatal cases. — No. 13 is that of a patient admitted late in invasion, 
t. 120°, p. 140, with all the characteristic marks but jaundice of acute 
spirillar infection : the blood contained large clusters of spirilla and 
many large nucleated cells : death took place five hours afterwards. 
Nos. 14, 15 and 16 belong to M., 50, who was admitted with his family 
all ill i^'ide Chapter on Contagion, the Ahmed family), and who sank 



SPHYGMOGRAPII TRACINGS. 



Plate I. 







DEATH-INVASION 6 DAY X.102.5 P.I3Z 




h h 


ly 


■ h 


^ 


V ' v_. 




\ 


X 


"\ 


V \ 


V 


\, 


si N 


\/ ^ 


V \ 




3 DAY APYRETIC 


INTERVAL 


T. 98.4 


P. 7 2 



14 



15 



16 



JbUMUAY, 10;6. — 11. V. C. 



RESPIRATION, IO3 

exhausted in three days ; the first and second tracings resemble those 
of survivors at corresponding stages of specific fever, and the last is that 
of the moribund state. 

These sphygmograph records are chiefly remarkable from the absence 
in them of the dicrotism so frequent in typhus and enteric, and trom 
their presenting blood-pressure signs : doubtless, the two conditions are 
correlated. 

I have above stated that whilst the febrile pulse was rarely dicrotic, 
it was almost invariably easy of compression, and at present I see no 
method of accounting for this discordance of clinical and physical signs, 
other than the supposition that the causes of obstructed circulation exist 
in the blood itself, being at first the multitude of spirillar filaments, and 
after crisis the ingress of large granule-cells. 

It will be perceived that tracings like the above, are not calculated 
to afford much help in prognosis. 

13. Respiratory System. Cough: Voice. — That the lungs suffer se- 
verely during the spirillar disease was shown in the autopsic records, pneu- 
monia and pulmonic congestion being common occurrences in the first 
interval, and a pale and inflated or collapsed state in deaths during 
primary and recurrent fever, and the second apyretic interval. The life- 
symptoms correspond, being similar (except in intensity) amongst both 
surviving and fatal cases. Those indicative of pneumonic congestion and 
inflammation were, as in other fevers, liable to be simulated or over 
looked ; whilst those attending the pallid lung-state constitute a kind of 
dyspnoea, which, taken with other signs, may be peculiar to certain forms 
of blood-infection including the spirillar. Nothing identical was ob- 
served in the course of ordinary remittents, at Bombay. 

Rapidity of Respiratory Movements : Morning and Evening Data 
in average surviving cases. 

M., 35, two days before critical fall of invasion-attack, resp. 34 per minute (t. 
104° '6, p. 124) not rising at the acme (as would appear), at fall the rate declined to 
14 p. m. (temp. 95° '4, p- 70) and was steady there, not following either temp, or 
pulse until after a brief relapse on lith day, when it rose to 22 p. m. (t. 104°, p. 1 12) 
and promptly declining continued at 14 p. m. for a fortnight longer. An adult man. 

F., 35 {vide Case IX.), just after the acme of invasion-attack, resp. 44 per minute 
(t. 104° '4, p. 140), and at fall declining to 26 p. m. (t. 96°, p. 78), rising alone to 
32 soon after and slowly declining during the tirst apyretic interval, as does the pulse 
but not the body-heat : during the well-developed relapse, respirations rose quickly 
to 40 p. m. on first day (t. 105° -6, p. 108) then following temp, rather than pulse, 
the rate dtclit ed moderately at fall (28 p. m. with t. 96° '6, p. 84) and corresponding 
with pulse declined to 22 p. m., being steady there for fourteen days, excepting a 
rise with brief relapse happening about then : just before this the pulse had gradually 
sunk to 54 p. m., there being no similar decline of breathing rate. During the relapse 
there was a little bronchitis. The influence of sex was manifest. 

M., 14, the rate was nearly the same as in the woman : very quick two days after 
the first crisis (40 p. m. wiih t. 98°"6, p. 100) it descended, like the pulse-rate; until 
the relapse, when it rose rather before t. and p. ; it followed the temp, during fever 
(maxima 40 p. m. , t. 104° -2, p. 150), declined promptly, yet moderately, at fall (22 
p. m., t. 96° •6, p. 76) and for twenty-one days longer the breath-rate averaged 20 
p. m., rising at irregular times, both with and without p. and t. Patient a youth. 

Extreme rates during fever may or may not correspond with those of 



104 . SPIRILLUM FEVER. 

temp, and pulse : the tendency is to such correlation, excepting when 
in the relapse the pulse, as usual, rises with progress of fever, the breath- 
ing-rate does not augment, rather declining towards the end ; the 
maxima, minima and mean rates are different in different cases ; and the 
normal preponderance of rate in females and the young appears also 
during this illness. 

In general, neither respiration nor pulse ascends proportionately to 
the temperature at initiation of relapse ; nor do they decline at fall 
(particularly does not the breathing-rate) in equal proportion. These 
statements are made upon the above data, and reckoning resp. i : p. 4, 
and : t. 5° -5. 

Variations from the above average-rates were not uncommon at all 
periods of illness, and seemed to be referable to several causes : mere 
height of fever was not in detail an invariable determining influence ; 
pulmonic congestion probably always led to increased frequency — cough 
or pain in the chest, with scanty, frothy sputa attending ; nervous excite- 
ment was sometimes the only apparent influence in causing undue 
frequency ; often muscular pains of the body ; and special interference 
with the action of the diaphragm, through either unusual turgescence 
and distension of the abdominal viscera, or excessive tenderness of parts 
in the upper zone and particularly the epigastrium. Several instances 
were noted of rapid breathing when the abdomen, though very tender, 
was not distended ; it might be even flat or retracted. In the normal 
state, the rate per minute of respiratory rhythm varies very largely. 

The stage of acme was often attended with extreme perturbation of 
the breathing, and at this turning-point of the attack, the respiration, not 
less than other functions, was probably always embarrassed. 

The period of the critical fall presented many variations : thus, of 
two adult men, in one the respirations were 26 with a temperature of 
94"^, p. 70 (no collapse), with a slight rise to 95°, p. 72, they declined to 
20 ; next day, with 95°'6, being 24 : in the other case, the breath-move- 
ments were 50 at t. 95°, p, 80 (collapse) and then declined with 
rise of temp.; they had been 58 at the moderate acme, and were much 
fewer in the succeeding relapse with a higher temperature ; cough was 
present during the invasion-attack only. The mean of seven ordinary 
cases was with temp, at main fall 96°"3, No. of respirations 23. 

Apyretic intervals. — So far as seen in hospital, the ordinary breath- 
rate was moderate, not continuing to decline, as, for a time, does the 
pulse : sub-normal rates were unusual, being seen only in elderly sub- 
jects and in conjunction with mental depression. 

Fatal cases. — In the briefer uncomplicated casualties during fever, 
the rates varied within the limits already named : even in an infant and 
a girl they were comparatively slow (lungs found unchanged) ; also in a 
man of 60 years {e.g. 25, with t. io3°.6, p. 120, shortly before death) and 
in a young man 40 per min. with t. io2°*4, p. 120 (lungs healthy). 
Complicated cases showed wider ranges, yet seldom extreme, except at 
the acme of attack. The comparatively slow rate in the infant (20-30 
p. m.) was remarkable. 

Character of chest movements. — When frequent, the breathing was 
usually more or less shallow : frecjuent and deep respiration was very 
rare and of l)ricf duration, except in comi>licated cases. 



RESPIRATION. IO5 

Form of movements. — Respiration mostly thoracic was the com- 
monest form ; its natural predominance in women was noted ; abdo- 
minal breathing being occasionally seen in young males and infants. 
General upheaval of the chest walls, and even an asthmatic type, were 
occasionally seen in fatal or complicated cases : and towards acme of 
fever, the type of breathing varied considerably, according to state of 
thoracic and abdominal viscera. 

Connection of respiratory movements with particular states of the lungs, 
— With the pale and inflated condition (4 cases), temperature was high, 
pulse very quick, breathing 50-70 per minute, not exclusively of one 
form, and dyspnoea not a prominent symptom ; moist sounds were 
audible in the chest : twice there were large, pale clots in the right 
heart, and the blood was charged with post-spirillar granule-cells. With 
the pale and collapsed state (5 cases), the organs were dry and dyspnoea 
urgent, according to degree of collapse, respirations 20 to 48 per minute, 
temperature varying, pulse frequent and small, the blood was full of 
spirilla or granule-cells, and both sides of the heart contained clots. In 
4 deaths at critical fall, the lungs were collapsed twice, or congested : 
the breathing was described as laboured, sighing, gasping or compared 
with bellows-action (as in cardiac embolism) : in the last-named in- 
stance, the base of one lung (collapsed) was saturated with fine, frothy 
serum and a widely distributed clot was found in the right heart cavities 
and pulmonary arteries. In two instances of vrell-marked abdominal 
breathing, the lungs were generally or partially collapsed, deep basal 
congestion being present once. The explanation of these phenomena 
is, at present, only presumptive. 

Respiratory phenomena at acme and beginning of fall. — Many in- 
stances were seen casually in the wards amongst survivors of extreme 
breath-troubles at these moments, when the blood undergoes a sudden 
physical change ; though only part of the general distress, yet the dys- 
pnoea with enfeebled heart-action sometimes seemed to predominate, 
and restlessness, drowsiness, moaning or noisy delirium might be as 
marked here as in fatal cases. Necessarily, the stress was of brief 
duration, and chance seemed to determine whether or not life should 
continue. A contemporary rise of temperature (seen or not) was doubt- 
less the rule, also abdominal fulness and tenderness in varying degree ; 
the respirations were shallow, thoracic and frequent, rising to 50, 60 or 
70 per minute ; and in extreme cases, the chest seemed fixed, the head 
was thrown back and nostrils actively working, the sufferer meanwhile 
tossing about in agony, and the expired air being perceptibly cold. 
Relief was almost always prompt ; and, like pulsation, the breathing- 
rate subsided slower than the body-heat. With urgent phenomena of 
this kind, it is not difficult to comprehend the comparatively frequent 
onset of pneumonia with and after the specific fever ; and many 
patients were reported to have died with troubled breathing suddenly 
supervening. 

Cough. — A mild degree of bronchitic congestion attended with cough 
and scanty, frothy expectoration, was noted in upwards of one-half 
the cases of fever ; such congestion being indicated on auscultation by 
coarse, moist sounds, and seldom by impaired resonance or signs of 



I06 SPIRILLUM FEVER. 

pulmonary oedema. These symptoms might pass through intermed'ate 
stages to confirmed bronchitis and pneumonia {inde Complications of 
the Respiratory Organs) : they usually supervened on or after 3rd day 
of invasion-attack, ceasing with or soon after the crisis ; yet not very 
rarely first appearing later in the post-febrile period in connection with 
mild secooidary fever : they were much less frequent during the first 
relapse, and subsequently. 

Some degree of pulmonic congestion was probably an invariable 
attendant on spirillum fever, whether not the act of coughing were 
noticeably excited ; and it is important to recollect that this symptom 
is not a precise indication of a really pathological state, readily becoming 
serious. Autopsies showed that in even fatal cases, cough alone had 
not much significance, for with it the lungs might after death be found 
in a quasi-normal state, or, on the other hand, inflamed to a degree 
much exceeding the urgency of this symptom during life. 

Voice. — Moaning as a sound of distress at acme of fever and during 
lysis-like defervescence, was a sign not heard in common fevers : even 
the infected monkey had its special cry. 

At the semi-collapse of crisis, the voice might be reduced to whisper, 
reminding the observer of its state in cholera. 

14. Liver. — The symptoms of pain, tenderness and enlargement are, 
in general, explained by the organic changes found after death, in con- 
temporary hospital cases differing from the surviving mainly by their 
greater severity. 

Constant pain in the liver was as rare as that in the spleen, and a 
fatal case showed it might co-exist with a seemingly unchanged condition 
of the gland. Hepatic tenderness may be so exquisite as practically to 
induce constant uneasiness to the patient. 

Tenderness, soreness, or contact-pain was common, and might be 
present alone, or, much oftener, with enlargement ; splenic and gastric 
tenderness usually co-existed with it. Its degrees were very various, 
and its presence was often elicited by action of the diaphragm {e.g. 
during cough), as well as through external pressure ; commonly limited 
to the hepatic region, it sometimes merged into a general sensitiveness 
of the upper abdominal zone. It has been described as sharp or cutting, 
when almost certainly acute hepatitis was not present ; the patient 
promptly recovering at the near critical fall. In 10 selected instances 
amongst the fatal cases, this sym])tom seemed to be associated with a 
pale or fatty state of the viscus 4 times, and with a mottled aspect once ; 
whilst 4 times the liver appeared nearly normal, and only once was 
there found such an inflamed condition of its serous investment as the 
urgency of elicited pain seemed often to point to. Acute fatty degene- 
ration, as elsewhere describeu, cannot always account for this local sign 
of disease, for in 4 cases on my list it was present without any entry of 
associated hepatic tenderness ; a preceding acute congestion, or paren- 
chymatous inflammation might, however, furnish a sufficient explanation 
in some instances. As with the spleen, so here, the tenderness some- 
times seemed to be neuralgic. Sympathetic tenderness, spasm and 
riLfidity of ihc adjoining al)doiiiina1 walls were (jften noted : such might 



THE LIVER. 107 

be present in the upper part of the abdomen, without marked hepatic 
and splenic implication during life, when after death the subjacent 
viscera were found much affected. Sympathetic pain in the right 
shoulder was also occasionally remarked ; and a dry, spasmodic cough. 

Enlargement of the liver, as ascertained by palpation through the 
abdominal walls and percussion of the chest, was noted in at least 33 
per cent, of all surviving cases ; it was found in 50 p. c of those at 
febrile periods, and in 10 p. c. of those at non-febrile periods. The 
corresponding proportions for fatal cases were 48-6 p. c. (total), 60 p. c. 
(febrile) and 33 p. c. (non-febrile) ; the chief divergence here (an import- 
ant one) being the last regarding the state of the liver in apyretic stages 
of severest attacks. 

During specific pyrexia the liver-dullness has measured 7 inches in 
vertical nipple-line : occasionally it extends upwards to the 4th inter- 
costal space (the abdomen being distended in conjunction with hepatic 
enlargement) ; and much more rarely the liver seemed to be pushed 
downwards by increased volume of the right lung : variations here were 
numerous, and obviously explicable. 

The left lobe of the liver is sometimes disproportionately enlarged, 
as proved by signs during life and the autopsic revelations : no fixed 
relations, however, obtained between this and gastric symptoms, for I 
have noted exquisite gastric tenderness (with haemorrhage) with a left 
lobe found after death to be actually small. 

Dimensions of the liver (never over-estimated) may, as was shown 
above, be greatly under-estimated from a variety of causes : hence the 
presumption arises that minor degrees of hepatic enlargement were often 
overlooked, for in this disease, especially, it would require unusual skill 
to avoid error with the lungs on the one hand and the stomach, intes- 
tines and abdominal wall on the other, all so liable to concurrent morbid 
change. 

Symptoms according to stage of Fever. — Invasion-attack. — Nothing 
definite was elicited respecting hepatic changes in the incubation- stage 
of first attack : in my own case there was not any uneasiness referable 
to the liver. 

First day : my scanty notes indicate that tenderness or fulness of 
the liver are more to be expected than splenic changes ; on the suc- 
ceeding day, they were distinctly intimated, with epigastric uneasiness; 
and in infants enlargement may be manifest. Third day : in 18 cases, 
hepatic tenderness attracted attention 1 1 times, and was present alone 
5 times ; its degree varied from the barely perceptible to the consider- 
able, adding to the patient's sufferings : it was usual in children, and 
found to be commonly most marked at evening with rise of tempera- 
ture : enlargement of the organ both upwards and downwards was 
usually present. Fourth day : in 24 cases, the li\er was implicated 16 
times, tenderness being oftenest noted ; enlargement might still be 
slight. Fifth day : in 23 cases the organ was enlarged or tender, or 
both, 14 times : when the acme occurred now, its condition might re- 
semble that of acute hepatitis ; dry cough may attend this state : on 
the other hand with even high fever, the liver may seem to escape 
lesion. Sixth day : in 25 cases, the organ was implicated 17 times: local 



I08 SPIRILLUM FEVER. 

symptoms were most urgent when the acme of attack happened now (9 
times), yet this event once, at least, passed without attracting attention 
and local signs were not necessarily proportionate to other symptoms. 
Seventh and eighth days: 16 cases, and the liver affected 11 times, 
sometimes more strikingly than before ; acme-period common, and it 
would seem not associated with liver changes so often as with splenic. 
Critical fall — whole period. In 32 cases the liver was perceptibly 
tender, turgid or enlarged 22 times : commonly the changes were of 
brief duration at this stage, and had nearly disappeared at its close. 

First Apyretic Interval. — First day : of 33 instances the organ was 
tender or enlarged, or both, 10 times at least : on the following day 
hepatic signs were reduced one-half, and still more on third and fourth 
days ; so that on the fifth there was noted only i case in 26, and on the 
seventh day not a single instance. Nothing was noticed of that re- 
appearance of symptoms on the last day or two of the interval, prior to 
relapse, shown by the splenic organ. 

First Relapse. — As the result of 155 observations made on the same 
series of cases as previously, it appears that whilst in the whole relapse 
the liver is affected in at least 32 p. c. of instances, it is not implicated 
uniformly throughout : thus, on the first day in only 8 p. c, on the 
second in 16 p. c, on the third in 25 p. c, on the fourth in 54 p. c, 
. on the fifth in 70 p. c, and on the sixth and seventh days in 43 p. c. ; at 
the critical fall, the gland was still affected in 32 p. c. of cases. These 
ratios are probably below the actual, but it may be allowed that the 
liver is not quite invariably implicated in the recurrent febrile attack, or 
always in proportion to intensity of fever. 

During short relapses, hepatic derangement was less in proportion 
to abbreviated duration : it was not so frequent as the splenic. 

Second Interval. — So far as appears from my data, the liver may be 
found affected in about one-third of cases on the first day of this period; 
on the second hardly at all, and subsequently to be quite free from 
obvious change, the resumption of a quasi-normal state being prompter 
than obtains with the spleen. Instances of exceptional persistence of 
symptoms were not here seen. 

The relationship of hepatic derangement to secondary fever was 
sometimes evident, and the subject is illustrated under that complica- 
tion : during ordinary symptomatic fever, the liver is not especially im- 
plicated : its connection with jaundice is detailed below. 

A few instances were seen of specific fever in patients previously 
affected with hepatic abscess : the local symptoms were then not ex- 
cessively exaggerated : thus, M., 30, had tolerably clear signs of abscess, 
during invasion there was very little exacerbation of hepatic pain, ten- 
derness and tumefaction, a slight diminution even of these symptoms 
took place after the first few days, but dysentery came on : death on 
the seventh day. The liver weighed 48 ozs. (after evacuation of ab- 
scess). Such instances are comparable to those of spleen-disease prior 
to specific fever ; and in both series, it appears that the local affection 
is not so much intensified as might be anticipated, by the superadded 
new infection. 

15. Epigafetrium. — The middle segment of the upper abdominal zone 



EPIGASTRIUM. lOQ 

was affected with pain, tenderness and distension in at least 20 per cent, 
of invasion-attacks and 30 p. c. of relapses : these symptoms were not 
always restricted solely to anatomical limit, and they varied much in 
intensity ; sometimes adding not a little to the patient's suffering. Upon 
some occasions, the sick brought from their homes, bore recent marks 
of cupping and caustic applications to the epigastric region. 

Pain was rare and not peculiar : the uneasiness of over-distension is 
not here alluded to. 

Tenderness was either acute and superficial (even strikingly so), or 
milder and elicited only on firm pressure ; it was most marked during 
pyrexia, following its exacerbations and being then attended with disten- 
sion of the region ; but without this fulness, it was not uncommon at 
and immediately after the critical fall. Gastric irritability, spontaneous 
vomiting and diarrhoea at the crisis, may be attended with collapse of the 
abdominal parietes. Fulness cr distension of the abdomen here varied 
much in degree, and was usually attended with a more or less tense 
state of the muscular walls : patients have expressed a sense of disten- 
sion, when none was present : and a similar subjective sensation was 
referred to joints, unchanged in aspect. 

The anatomical complexity of structure in and around the epigas- 
trium, would of itself suggest a manifold explanation of the above 
symptoms ; and autopsic data point to the same influence : thus, in 10 
selected instances, there was found congestion of the gastric mucous 
membrane alone 2, or with petechia; and diphtheritic inflammation of 
the ileum i ; disseminated congestion of the small intestines 2, or more 
localised congestion of the ileum 2 ; sub-peritoneal petechiae 2, and 
vascularity of Peyer's patches and large intestine i. Intestinal conges- 
tion seemed to have been present, without marked epigastric or umbi- 
lical tenderness ; and great or intense vascularity of the stomach (mid- 
region or diffused) together with petechiae beneath the mucous mem- 
brane, was twice seen after death with no account of epigastric tender- 
ness during life (stimulants had been administered shortly before 
decease) ; in other instances where tenderness had been a marked 
symptom, the stomach seemed to be healthy. I have shown that acute 
gastritis is, at least, very rare ; and besides patients often become too 
rapidly relieved of epigastric, uneasiness to permit the idea of organic 
lesion in these cases. Acute congestion of the stomachal mucous mem- 
brane probably existed in a case of fatal hsematemisis marked by acute 
local symptoms prior to vomiting, and by local pallor of the tissues after 
deatii ; and in a modified degree, this state may be even common 
during fever. In the apyretic condition, the tenderness sometimes 
seemed to be neuralgic : it also appeared to arise from personal idiosyn- 
crasy, and was common to groups of cases, probably under one infection. 
It was rare in children, and at shorter febrile attacks ; it might exist 
alone, and had no certain relation or degree to vomiting, even when 
the latter occurred at crisis. It was most pronounced in the severer 
cases, forming one of the characteristic phenomena of 'acme.' 

Epigastric tenderness and fulness, on some occasions, appeared to 
be attributable to enlargement or acute congestion of the uncovered left 
hepatic lobe, which overlies the stomach ; and this view was supported 



Iia SPIRILLUM FEVER. 

by post-mortem examination in three striking instances, but exceptions 
are known. 

In another instance, surviving, the site of extended tenderness and 
its production on deep pressure, conveyed the impression that the duo- 
denum might be congested as seen in autopsies : there was a yellow 
conjunctiva and vomiting of food ; vide Case IX., which also on last 
day of relapse (with a spleen less tense than before) showed pain on ■ 
pressure over hepatic, epigastric and inner half of splenic regions — this 
last limitation being singular. 

In a third case at crisis of relapse, it was noted that the epigastric 
neuralgia (then the main symptom) was excited by firm pressure below 
and to right of ensiform cartilage, over probable site of the solar plexus. 
Counter-irritation would relieve such symptoms. 

More diffused or general abdominal uneasiness was seen in various 
forms and many degrees. The most characteristic state during fever 
was acute tenderness with fulness of the entire upper abdominal zone 
including the epigastrium and both hypochondria ; seldomer was the 
umbilical region affected (independently of dyspepsia, diarrhoea and 
worms) when it seemed possible that scattered congestions or petechial 
extravasations of mucous, muscular and serous coats of small intestine 
were present, or similar changes in omentum and mesentery. Hypo- 
gastric uneasiness elicited on direct pressure, or by coughing, or the 
erect posture, and not attended necessarily by fulness, was occasionally 
witnessed ; it did not appear connected with the urinary bladder, being 
rather referable to known vascular changes in the lower part of the 
ileum, and end of large intestine ; iliac gurgling and tenderness, on 
either side, were rare, yet they were noted (concurrent diarrhoea absent) 
on the right side, in connection with demonstrated congestion of the 
lower end of the ileum and of csecum (ulcers never present) : lumbar 
pains were not traced to the colon. 

General distension and great tenderness were seen at the close of 
some fatal cases, which after death showed parietal and visceral pallor 
of peritoneum, paleness and great distension (? paralysis) of muscular 
coat of stomach and intestines, with pallor of the mucous membrane 
except where congestive patches or small extravasations had been formed. 
The liver, spleen and kidnies were characteristically enlarged, and full 
of blood : further, some cases showed subserous petechiae, and the 
most characteristic of all diphtheritic enteritis at the termination of the 
ileum. 

Besides the anatomical lesions already mentioned as possibly asso- 
ciated with these vaguer symptoms, there is to add over-distension of 
the muscular coat of stomach or intestines, and petechial extravasation 
in the diaphragm and beneath the right rectus abdominis muscle, which 
I have also noted in similar association. 

In my enquiries the state of the pancreas did not attract special 
attention, nor were the solar plexus and sympathetic ganglia so strikingly 
changed in aspect : a minute examination of these parts was not 
made. 

Epigastric Symptoms accorditig to stage of Fever. — Invasion -attack : 
absent, so fai us known, on the first day, in 4 cases they were noted 



.' THE SPLEEN. Ill 

once on the second morning when neither splenic nor hepatic signs 
were present : on the third day they were entered in 28 p. c. of cases, 
on the fourth much oftener, and on the fifth, sixth and seventh days in 
about the same proportion ; at the close of fever, including the acme, 
they were noted in 63 p. c. of instances ; and in 50 p. c. at the fall. It 
would appear that these symptoms are commonest at the onset and 
close of attack, especially at the acme, and in general do not present 
that gradual increase in frequency with progress of fever which is per- 
ceptible in hepatic and splenic phenomena : they bear no very evident 
relation in intensity to other symptoms. 

First Interval : Whilst present in 40 p. c. of the above pyrexial cases 
their proportion during this non-febrile period declined to 9 p. c, thus 
indicating clearly their connection with fever. On the first day these 
symptoms persisted in the ratio of 20 p. c, on the second to the extent 
of 16 p. c, and of only 4 p. c. on the third day ; after which time their 
occurrence seemed incidental ; on the seventh day they had ceased. 

First Relapse : present on the first day in 16 p. c, then in a ratio 
rising to 33 p. c. on fourth day, to 60 p. c. on the fifth when the acme 
was frequent ; these local signs were noted in about 30 p.c. of all febrile 
cases. At the critical fall they persisted in 40 p. c. During this recur- 
rent attack they seemed to augment with.progress of the fever. 

Second Apyretic Interval : Epigastric symptoms were still present in 
some cases on the first day of reaction, but very rarely on the second ; 
and subsequently they were noted in only one instance of a lad, who 
showed some epigastric tenderness several days longer. 

16. Spleen. — Changes found after death, may be taken as a guide to 
those prevailing amongst survivors ; they are, briefly, enlargement, in- 
farctions (so-called), softening, and, very rarely, inflammation. 

The local signs noted at the bedside were pain, tenderness and 
tumefaction or swelling of the spleen ; and I now proceed to discuss 
their comparative frequency and significance with regard to the ascer- 
tained lesions named ; for, degrees apart, there is no reason to suppose 
any essentially different alterations prevail in ordinary attacks of fever. 

Acute pain in the region of the spleen was very seldom noted, and 
this fact accords with the rarity of recent inflammation of the organ. At 
the acme of attack brief, paroxysmal pain may be felt, which subsides 
with the fall. The symptoms of pleurisy have been noted to commence 
at this time, limited to the left side, and subsequently neuralgic pains in 
the left shoulder. 

Dull, aching or dragging pain, or a sense of weight and tightness 
constantly present, and augmented by coughing standing or walking, 
was not uncommon both during and after fever, together with enlarge- 
ment or possibly limited adhesion of the splenic serous investment. 

Neuralgia. — Considerable tenderness, seemingly neuralgic, may re- 
main for some days after the fall and diminution of volume ; and there 
may then arise sympathetic or neuralgic pain in the left shoulder. 

Tenderness or pain elicited by pressure from below, outside or above 
(through the diaphragm), was a very frequent symptom. Usually sharp 
it varied much in degree, being sometimes revealed on mere touch 
or only on firm pressure over the splenic region. During fever it 



112 SPIRILLUM FEVER. 

commonly attended enlargement of the organ, without being proportionate 
to this ; and at the apyretic periods, it might be indicative of sub-acute 
organic changes. In its more exquisite form, it co-exists with tenderness 
of the upper abdominal zone, and possibly of the abdominal parietes : 
there is then usually febrile exacerbation, and commonly the acmal. 

Morbid anatomy has not yet furnished a complete explanation of 
this symptom ; thus, of lo instances analysed 2 showed a spleen seem- 
ingly unchanged, 3 large and firm, 4 large and infarcted and i somewhat 
softened. As in 7 other instances the spleen was not tender, with a 
seemingly normal aspect thrice, or with softening as often, and also not 
tender with infarcts once, I am unable to specify any invariable condi- 
tion as alone associated with splenic tenderness. Enlargement and 
tension during fever do not necessarily entail contact pain, but when 
coming on late with typhoid symptoms, then local tenderness will 
usually be present and may be marked. 

In one such case, the spleen became abruptly enlarged and tender 
just before the perhirbatio critica (which was very pronounced), and I 
thought it possible that infarcts were forming ; yet such could hardly 
have happened, since with the fall the spleen promptly subsided and in 
three days was hardly detectable, though still the seat of uneasy sensations. 

That ante-mortem softening of the spleen is not usually attended 
with local tenderness seems to be clear ; and in 2 cases when the spleen 
capsule was thickened and opaque, there is no entry of tenderness on 
pressure during life, these changes being evidently not recent. Unusual 
firmness of consistence, with or without enlargement, was not generally 
accompanied by tenderness ; and during fever increase of volume with 
a consistence almost amounting to hardness, may be present alone until 
the acme of attack, when acute sensitiveness supervenes. Changes of 
consistence felt during life necessarily imply augmentation of size, yet 
no rule obtains regarding concurrent degrees of either change, except 
that a much-enlarged organ was always firm to touch : in all cases, the 
state of the abdominal parietes has to be taken into account. 

Splenic atrophy was not detected in the living subject. 

Splenic tumour. — In nearly one-half of the data under analysis (which 
includes cases seen both early and late in the epidemic, and at all stages 
of fever) there was some palpable enlargement of the spleen ; and this 
proportion is doubtless under the correct ratio. Having, however, 
shown elsewhere that, in even fatal cases, the splenic tumour is not in- 
variable, it may be admitted that sometimes the organ is not consider- 
ably augmented in survivors : with regard to minor tumefactions, con- 
siderable difficulty exists in their detection ; and even the larger degrees 
may be under-estimated. As often as not, I find in test examples a 
fairly close correspondence between post-mortem dimensions of the 
spleen and those noted just prior to death ; yet as the divergencies 
were sometimes marked, it becomes desirable to quote the exceptions. 
The following remarks include references to the liver also, the state of 
which was commonly noted at the same time : — abdomen full, tense 
and tender, splenic and hepatic enlargement not detected ; yet after 
death early next day the liver was found to weigh 60 ozs., its left 
lobe projecting somewhat into the epigastrium, the spleen weighed 
19^ ozs., and also was of firm consistence. In this representative case, 



THE SPLEEN. II3 

the state of the front abdominal wall tended to conceal the actual con- 
dition of the viscera within, and I do not see how such impediment 
could be overcome. Displacement by the neighbouring organs must 
also account for anomalies like the following : — Spleen reported of 
nearly normal dimensions during life, after death found to weigh 14 ozs. 
(infarcts) ; as normal, yet found to be 1 2 ozs. ; as only splenic fulness, 
and yet an organ of 17 ozs.; as no perceptible enlargement, and yet 
weighing 24 ozs.; and spleen not felt, yet post-mortem weight 11 ozs. and 
infarcts present. More definite estimates may be nearly as illusory ; 
thus — abdomen distended and tender just before death, Uver pushed 
upwards and not projecting more than i inch below the r. costal margin, 
yet it weighed 4 lbs. 9 ozs. (73 ozs.) ; the spleen reached 3 inches below 
1. costal margin and weighed 36 ozs. : again, abdominal walls tense, 
liver estimated to present only normal area of dullness and then found 
to weigh 68 ozs.; spleen more correctly termed large, its weight 17 ozs. 
Other data were these — liver reaching to upper margin of 6th rib in 
nipple line, and downwards 2 inches below the c. cartilage, with weight 
73|- ozs.; spleen reaching to upper margin of 8th rib and to i^ inch, 
below c. margin, inwards 3I in. from median line ; its weight 38^ ozs. 
(infarcts) : liver reaching upwards to 5 th rib and downwards one inch 
free, its weight 69 ozs. ; spleen thought not to be enlarged, its weight 
16 ozs., or more than double the normal. All subjects young adults and 
generally males. Few words are needed to explain the above discre- 
pancies, and I will only add that besides the varying condition of the 
abdominal walls, and of adjoining viscera, the consistence and fixedness 
of liver or spleen have some influence ; since a firm, resisting mass will 
be readily estimated, when a more yielding one of the same volume 
might slip aside. If doubt existed, I usually turned the patient on 
his side and had the thighs fixed, employing then palpation and 
percussion. 

An excessive estimate of liver or spleen volume was never made, 
and it will be seen the tendency is to err in under-reckoning ; for this 
reason and upon pathological grounds, I infer that visceral enlargement 
may more habitually approach the ratio in fatal cases (76 p. c), than 
appears from my analysis of survivors alone (40 p. c). Besides, when the 
data are arranged according to stage of fever, a close resemblance as 
well as significant difference, becomes apparent ; thus, of total deaths 
during invasion-period, splenic enlargement was found in 70 p. c. ; of 
total survivors at the same period an equal ratio obtains, and may have 
been larger : during the first apyretic interval, splenic enlargement was 
noted in only 15 p. c. of survivors, but in 58 p. c. of cases dying at this 
stage ; and lastly, during the first relapse, amongst survivors splenic 
tumour existed in somewhat over 40 p. c. ; in the fatal cases, 100 p. c. 

During febrile turgescence, the spleen becomes more or less fixed, 
though still moving with diaphragm ; and during apyrexia, it is easily 
displaced. After death, its projection beyond the costal margin is less 
obvious than during life. 

Splenic Intumescence at different stages of Fever. — That the dimensions 
of the spleen tend to augment progessively during the pyrexial attacks, 
and to subside in the apyretic intervals, is shown by the following data, 

I 



114 SPIRILLUM FEVER. 

Invasion-period. — Of the state of the organ during incubation-stage 
of man, nothing is known ; only in my own late attack I failed to detect 
a change : the spleen seemed to be congested in a monkey killed at this 
stage. 

First day of fever : in 4 cases known to me it is probable that 
subjective or objective change would have been noticed, if present : 2 
children had probably a tumid and tender spleen on this day, and a 
man with prior malarious hypertrophy displayed in the evening-time a 
slight increase not perceived earlier in the day. 

Second day : that the organ may be hardly or not at all affected in 
the morning appears from the records of 3 cases, although there 
might be hepatic and epigastric tenderness, and considerable fever. In 
one of these instances with the evening exacerbation the spleen became 
tender and probably enlarged, and in an infant it projected beyond 
the costal cartilages. 

Third day : in 18 cases no change noted in 8, in 10 tender- 
ness alone or with enlargement, both in varying amount. The act of 
coughing or standing and walking, may elicit a painful sensation not 
before experienced. 

Fourth day : in 24 cases the organ enlarged or tender, or both, 
1 3 times ; it was so little changed as not to attract notice 1 1 times. 
Individual cases varied, but it was sometimes distinctly stated that the 
spleen was not enlarged, even with high fever : increase of sensibility 
commonly attends. 

Fifth day : in 25 cases spleen decidedly implicated 19 times, as 
above, and sometimes exclusively of the liver. When the acme of 
attack happens now, the local suffering may become considerable ; on 
the other hand, the organ may be hardly affected, to all appearance, 
even at this date. 

Sixth day : in 24 cases the organ enlarged or tender, or both 17 
times : little or not affected 7 times. The acme of attack being now 
frequent, splenic excitement coincides (e.g. 9 in 1 1 of the cases), but is 
not quite invariable or proportioned to intensity of other symptoms. 
Contact-pain may be now manifested for the first time, and the patient 
complain of uneasiness leading to change of posture. 

Seventh, eighth and ninth day : in 14 of the 16 cases scrutinised 
there was decided splenic implication, and the 2 exceptions were not 
well expressed ; the acme of attack occurred 9 times and almost in- 
variably with splenic exacerbation. It seems that enlargement and 
firmness of the organ augment with duration of pyrexia, but not the 
local tenderness. 

Critical fall. — In 32 cases the spleen was perceptibly enlarged or 
tender, or both, 24 times at the beginning or in course of the fall ; 
it seemed to be unchanged 5 times and may have been so in 3 other 
instances. When the fall was prolonged, the organ sometimes became 
reduced to near normal dimensions at its end ; and always volume and 
tenderness declined, even promptly, with progress of the crisis. In a 
very few cases the spleen was said not to be perceptibly changed from 
the normal at this time, as previously it had not been. Gastric and 
hepatic changes usually coincided. It has been noted that the organ 
became very firm at this time. 



THE SPLEEN. 115 

Summary. — Splenic implication consists of enlargement and tender- 
ness, which though related, are not always proportionate to each other, 
or to the attendant pyrexia : contact-pain seems to be an early and a 
paroxysmal phenomenon, whilst enlargement is rather progressive : in 
general, the spleen has shown a tolerably regular augmentation of these 
signs in frequency, from 60 p. c. of cases on third day of attack to 
90 p. c. at acme : at the critical fall {i.e. before its completion) 
splenic disturbance persisted in 75 p. c of cases, but it speedily 
subsides. Several of the above statements apply to the recurrent febrile 
periods. 

First Apyretic Interval. — The notes of 171 cases taken at this negative 
stage show that splenic changes were noted (being sometimes prominent) 
in at least 34 p. c. of cases on first day after end of critical fall, and in 
19 p. c. of those on second day ; but quickly became less apparent, 
till on the fifth day they were entered in only 4 p. c. of cases. 

Even if approximately correct, the above data show a close association 
of the local signs with pyrexia and spirillar blood-infection ; enlargement 
persists longer than tenderness : smart febrile rebound may take place at 
this time without the spleen being affected, and also local inflammations, 
neither complication being specific. These data reveal another fact of 
interest ; thus, after the 5th day, i.e. on 6th and 7th or day of relapse in 
this series, the organ tends to become affected again, the proportion of 
instances displaying some tenderness, fulness or tumefaction rising to 
10 and 15 p.c. respectively, or nearly that exhibited upon the first 
advent of recurrent fever : the explanation here seems to be that with 
the specific incubation-period (generally of about two days' duration) 
the spleen tends to show signs of disturbance : this concurrence may 
at all times be difficult to demonstrate, and, in fact, was apparent in 
only 3 of 1 2 instances noted of expected relapse ending with fever : 
further and closer enquiry is desirable, yet it remains a clinical fact that 
spirilla may be present in the blood without pyrexia or palpable splenic 
derangement. 

P'irst Relapse. — Of 129 observations of fully-developed recurrent 
attacks, decided splenic implication was present in 42 p. c. ; as detailed, 
it was noted in 12 p. c. of cases on the first day, 24 p. c. of those on 
the second, in 36 p. c. on the third, in 73 p. c. on the fourth, 70 
p. c. on the fifth and in 43 p. c. (cases few) on sixth day : in 88 p. c. 
of all cases at acme and in 60 p. c. of cases at the critical fall. This 
series indicates a tolerably uniform increase in splenic tumefaction, with 
continuance of pyrexia ; yet neither at beginning nor in its course does 
the intumescence necessarily accord with intensity of fever, following 
rather the ascertained degree of spirillar blood-infection. The inclusive 
local signs are the same as in the primary febrile attack, being perhaps 
less pronounced and persistent, and varying more. 

Second Interval. — -The abated frequency of splenic implication con- 
temporary with shortened duration of fever-periods, has been already 
indicated ; and though at the critical fall of relapse the organ was still 
largely involved, yet towards the end of this stage (not seldom pro- 
longed) its enlargement had often subsided or was on the point of dis- 
appearing, and consequently with reaction and rise of temperature to 
the normal, the presence of splenic tenderness or swelling was noted in 

I 2 



Il6 SPIRILLUM FEVER. 

only one-fourth of the cases under analysis. This is a considerably less 
proportion than was found at the corresponding date of first apyretic 
interval, and it was not long maintained ; being on the third day reduced 
one-half, and on the fourth remains of splenic implication were detec- 
ted in only 2 subjects of 28 belonging to my later series : one of 
these was a woman of 56 years who showed on the sixth and seventh 
days a slight increase of the splenic enlargement, without tenderness, 
and no other sign of a second relapse ; and the other was a man of 25, 
in whom an isolated paroxysm of fever afterwards occurred on the 
twelfth day. 

In some cases, the spleen does not revert to its normal condition 
directly or uniformly ; and traces of the changes it has undergone during 
the active periods of blood-infection, are not for a long time effaced. 

It also appears that the spleen may continue to furnish evidence of 
periodic disturbances of the system, not amounting to distinct third or 
fourth relapses ; yet to be considered as recurrent events, due to re- 
peated auto inoculation. 

Second Relapse. — In a later series of 28 cases there were 6 instances 
of second recurrent paroxysms, displaying the usual variety of form : 2 
were fully developed relapses extending over four or five days, and of 
these in i the spleen was enlarged and tender ; but not before fever set 
in and not so long as it lasted, diminution of the organ commencing one 
day before fall of pyrexia, though simultaneously with a slight decline of 
temperature. In the other case, the spleen had been affected with 
malarious enlargement ; on the morning of relapse it was noted as being 
much reduced in dimensions, and with the advent of fever it became 
tender and larger : some tenderness persisted for ten days after the fall, 
when again feverishness came on in the form of a prolonged series of 
minor daily exacerbations (probably representing an abortive third re- 
lapse), and the spleen once more displayed unusual tenderness for a time 
briefer than the pyrexia, or not proportioned to it ; its volume did not in- 
crease equally, and with the resumption of normal temperature level, was 
found to be less than ever before : this case is detailed as an example of 
conjoined malarial and spirillar infection. 

There were 2 examples of second relapse in the form of brief yet 
smart isolated paroxysms, occurring on the 10-12 day of apyretic 
interval : in one of these splenic implication was not noted at the be- 
ginning of fever (spirillum present), and in the other there was increase 
of pain or tenderness in an organ previously not sound, with no enlarge- 
ment (t. 1 05° "4, spirilla probably present). In a third case belonging to 
another series, the local symptoms, though brief, were acute enough to 
suggest ' splenitis.' 

In other 2 instances this relapse was represented by a long, low rise 
of temperature coming on a fortnight after the last fall ; in both the 
spleen was decidedly enlarged and tender, yet not immediately before 
the commencement of pyrexia ; in one the local signs slowly declined 
after its cessation, and in the other a little before the final rise, not in- 
creasing with rebound and still persisting in mild degree after the 
fall. 

The same series of cases furnished 3 instances, at least, of late 
])criodic symptoms (about 6th day of interval), once febrile without de- 



THE SPLEEN. II7 

tected spleen-enlargement ; and twice non-febrile, with either enlarge- 
ment or tumefaction alone of this organ. These phenomena might well 
be regarded as indicative of suppressed relapse. 

Two examples of intercalated paroxysm happened in the same series, 
during the first apyretic interval ; the specific character of one paroxysm 
was demonstrated, yet in neither instance was splenic derangement 
noted before, with or after the attack ; possibly from want of sufficiently 
numerous observations. 

I should add that the number of later febrile and splenic derange- 
ments might have been larger in this representative series, had not 
several patients left hospital too soon after the second relapse to permit 
of adequate study of their cases. 

During secondary fever and that symptomatic of local inflammation, 
the spleen was rarely implicated to a considerable extent, and never at 
early date ; it is, however, possible that minute and parenchymal lesions 
would not be manifested by local signs, and that these ' infarctions ' of 
the spleen could not be diagnosed during life. 

I would here add that whilst splenic implication, as clinically re- 
vealed, is a most frequent feature of the spirillar disease, and even 
intimately associated with fatal terminations ; there is evidence of its not 
being a strictly invariable attendant. In the monkey, I never found the 
spleen much changed in aspect ; and I should regard all extremer 
alterations of this organ in man, as truly incidental results of infection : 
this view does not affect the clinical interest of the present subject, for 
it may be said that marked or serious splenic implication is always con- 
tingent. 

The anatomical relations of the spleen and adjoining viscera of ab- 
domen and chest, become of practical interest where one or more of 
these organs are so much altered in volume, weight or sensitiveness as 
to displace or disturb others near them. There are well-known illus- 
trations of this subject in several local and general diseases ; and, 
without being peculiar, they were frequent during the course of spirillum 
fever. 

Clinical Review of the chief Abdominal Symptoms. General fre- 
quency : — Limiting attention to the contents of the three regions 
composing the upper abdominal zone, I find at invasion-attacks the 
following percentage of entries amongst patients surviving : — Spleen 70, 
Liver 66, Epigastrium 40 ; and in first relapses the following :— Spleen 
45, Liver, 32, Epigastrium 30 p. c. Therefore, all of the organic dis- 
turbances implied are fewer during the relapse, the diminution being 
most apparent as regards liver and spleen. Complete information re- 
specting the commencement of invasion-attacks is still wanting, and 
might lead to a modification of the preceding statements ; yet not, I 
think, to their subversion. 

General course of local changes. Invasion-attack. — There is but a 
moderate increase of symptoms with progress of fever, from third to 
seventh day or later. At the acme, a common exacerbation is clearly 
indicated and probably is never wholly wanting. Even during the cris-is 
some symptoms persist until its end. 

First Interval. — The chief feature is a gradual yet prompt subsidence' 



Il8 SPIRILLUM FEVER. 

of local symptoms from the first day to the seventh ; an exception con- 
cerns the spleen, which shows a distinct renewal of disturbance in the 
two days preceding relapse, or at corresponding dates when no febrile 
recurrence takes place. 

First Relapse. —Without absolute similarity there is conformity in the 
three groups, the common feature being a gradual accession of symptoms 
from first to sixth or seventh days ; at the acme and fall exacerbation 
was noted, but the total derangement is decidedly less than at invasion. 
During the succeeding apyretic period, the spleen, chiefly, displays some 
of the previous changes. 

Comparative frequency. — Amongst themselves these several groups of 
symptoms at febrile periods maintain a ratio, which is almost the same 
for first and second attacks ; viz. — Splenic 40 to 42 per cent, of total 
syinptoms, hepatic 35 to 30 p. c. and epigastric 28 to 24 p. c. (first nos. 
are those of invasion). 

Combinations, — In general, none of the three groups existed alone 
is more than 5-7 p. c. of all positive instances ; the exception being 
that during relapse, the spleen was not seldom the sole organ affected. 
Using the expressions L. s. e. for hepatic, splenic and epigastric respec- 
tively, the most frequent combination was s. L. e. (30 p. c. invasion 
and 22 p. c. relapse) and next s. l. (30 p. c. and 15 p. c.) ; L. e. was 
seldom seen alone (6-9 p. c), and during invasion s. E. never ; but 
during relapse in about 8 p. c. 

Comparison of the preceding data with those taken from fatal cases 
and autopsies.— A thorough comparison of the clinical phenomena pre- 
sented by survivors and by those dying, is not here attainable. Fatal 
cases were often first seen in a moribund state, or they were complicated 
with symptomatic fever ; hence, but a small residuum remained avail- 
able for analysis. The general result, however, appears that splenic 
symptoms were noted in 60 p. c, at least, of all casualties : and the 
hepatic in 65 p. c, ; the epigastric were seldomer noted. As most 
casualties happened during, or inimediately after, the invasion-attack, 
these numbers agree fairly with those then given for survivors ; and 
they indicate that the difference here, resides not in frequency so much 
as in intensity, of the local symptoms. 

The other supplemental series of autopsic data has been already 
referred to ; after the necessary sifting and arrangement they, too, prove 
to be scanty, only showing that whilst a certain range obtains in the 
structural changes and dimensions of liver and spleen, there is yet a 
niain accordance with the life data, as regards the increase in volume 
of these organs towards close of the febrile attacks. 

The inference follows that, as regards the abdominal organs chiefly 
implicated in spirillum fever, a close similarity obtains between frequency 
of symptoms and (in all probability) of structural changes, m both sur- 
vivors and those dying from fever alone. 

16. The Urine. — Though there were some unusual obstacles to 
full enquiry here, owing to native prejudice or inattention, and the want 
of adequate assistance ; yet a few interesting data were acquired, which 
may be arranged as follows. Quantity, aspect, reaction and specific 
gravity of the urine at different stages of illness. 



THE URINE. 119 

Febrile attacks. — Respecting the course of invasion only scattered 
information was obtained, prior to the acme and fall. In 9 typical cases, 
the quantity was usually diminished, but twice reported as copious, 
aspect little changed or high-coloured, sp. gr. 1010-18 (mean 1015), 
reaction commonly acid, bile ingredients present, chlorides diminished, 
traces of albumen rare (i in 6). I do not recollect seeing in a native 
patient the scanty, red urine, of high specific gravity and with brick- 
dust sediment, which is found in other febrile diseases ; and there did 
not appear any definite connection of urine-changes, with prominent or 
unusual symptoms. 

At or near acme, the urine was usually scanty, high-coloured, clouded 
yet without sediment, reaction acid, sp. gr. 1010-18 ; no lateritious 
deposits on coolmg were seen, and very seldom the frequent micturition 
due to an irritated bladder. Mucous cloudiness always scanty, and 
degree of acidity never much pronounced : a sense of scalding was 
once mentioned with urine clear, though high-coloured, sp. gr. 10 19, 
no albumen present : once the urine was very copious, sp. gr. 1010. 
Even at this acute stage of fever, albumen is not always to be detected 
by ordinary means. 

With the critical fall, the amount of urine varies ; thus, it may be 
plentiful, but is commonly scanty and occasionally secretion seems to 
be suspended for a time, no urine being present in the bladder, and the 
general aspect of the sufferer approaching to that of a cholera patient 
in the state of collapse. The quantity of urine passed at this stage did 
not appear to be regulated by the copiousness of cutaneous transpiration; 
or, so far as ascertained, by the amount of fluid ingesta. Once the sp. gr. 
was 1020, and chlorides in excess : other instances were the following : — 
F., 35, the temp, during night falling from io4°-8 to 97°'2, with pro- 
fuse sweating, 35 ozs. of urine were passed, high-coloured (bile-pigment), 
somewhat clouded yet without sediment, acid reaction, sp. gr. 1006: 
she was particularly disinclined to drink water, but had extra milk 
allowed. 

M., 35 (her relative), the t. falling at night from 105° to 99° without 
sweats, 15 ozs. of urine were passed in the morning, high-coloured, 
cloudy (no sediment whatever), sp. gr. loio, acid in reaction : at 4 p.m. 
the temp, had sunk to 95° "6 and no urine was seen until midnight. 
Sheer depression, the spleen large, pupils normal and no head-symptoms. 
For one instance in which at beginning of the fall, the urine was dark 
as if from the presence of blood (urates only being found) see Case XXII. 
detailed above under ' Lysis.' Real haematuria was never observed in 
Bombay : nor any other example of critical urine-changes. 

At reaction after crisis, the urine is apt to be scanty, then attaining 
its highest known density, or a specific gravity of 1015 to 1022 (seldom 
the higher number) ; its quasi-febrile aspect being retained. 

When the temperature persists at its lowest for one or two days, the 
urine continues as above ; and with systemic reaction I have noted a 
brief interval, on the second or third day, where the secretion is scanty, 
yet pale and of very low density ; afterwards its amount increases, and the 
general aspect of non-febrile condition is assumed. For a striking in- 
stance of prolonged depression and anuria, without any signs of uraemia, 
see Case XXI. above, under ' Crisis.' 



120 SPIRILLUxM FEVER. 

At both acme and fall of the invasion-attack, careful microscopical 
search was made on several occasions, for evidence of organic renal 
degeneration amongst native subjects ; the result being always negative. 
First recurrence. — From fuller data of a well-developed relapse 
occurring in an adult woman (Case IX.), it appears that during fever 
the quantity of urine passed diminishes from first to last ; in her case 
being 66 ozs. on the first day, 60 on the second, 31 on the third, 30 on 
the fourth and 28 on the fifth or last day prior to fall ; its specific gravity 
at the same time rose from 1006 to 10 13, augmentation at the last being 
most decided. On the second morning the pale tint became deeper, 
and from the second evening the urine was high-coloured, being also 
very clear ; it was very high-coloured (or almost red) on the last morn- 
ing near the time of acme, yet showing no sediment on long standing 
(no blood present) : the urine was cloudy from the second day onward, 
but never furnished a deposit on standing : it was distinctly acid 
throughout. 

Microscopic examination of the deeper strata in specimens placed 
at rest, was carefully made, towards the close of the attack especially, 
and always with negative results as regards the evidence of renal disease: 
scanty dumb-bell crystals of urates, or triple phosphate, and a few 
bacteria, with, on the last day, a little squamous epithelium (vaginal) 
were alone detected, and not a sign of renal cell or tube-cast. Even 
when albumen was present distinctly in the urine, organic debris were 
not seen ; and, I may add, this holds good for the critical fall. 

During a relapse lasting part of two days (acme 104°, spirilla in the 
blood) the urine Avas diminished somewhat in quantity, though still 
copious, its specific gravity hardly raised (1004 to 1006), its hue altered 
to yellowish or brownish and its aspect became clouded for a time : the 
reaction was always acid : patient a male adult. 

In the case of a lad under close observation, the urine was copious 
on the first day and less pale than before, soon becoming tinged yellow 
(no play of colours on addition of nitric acid), there being some hepatic 
tenderness but no perceptible jaundice : specific gravity at first not in- 
creased : changes on the second day (high fever still) were not more 
marked, there being noted a tendency to rapid decomposition ; on third 
day, urine scanty, high-coloured, clouded, sp. gr. 1015, and scanty 
at the acme : here, too, microscopic examination gave negative re- 
sults. 

A Mussulman adult furnished urine on the first rise of temperature 
copious, pale, and of rather less density than before (1007) ; on second 
day, it was clouded and denser (1012) ; on third day high-coloured, 
cloudy (no sediment) and sp. gr. 1017, bile-acids and bile-pigment being 
present at this time and on next day; on the fourth, still plentiful (57 
ozs.) and high-coloured ; on fifth day it again became light-coloured, 
though clouded, and was copious (sp. gr. 1010-15) ! ^^ this time the 
liver seemed nearly normal whilst there was deep jaundice, and the man 
passing into the typhoid state, e. t. io5°-6 : on the following night 30 ozs. 
of high-coloured urine were passed, sp. gr. 1015, clouded, acid, no 
albumen ; the brief acme then ensued, and fall. 

The general state of the urine at acme was seldom to be learnt : in 
an adult woman the secretion passed soon after this epoch measured 



THE URINE. ■ 121 

i6 ozs., was very high-coloured (red), clouded (no sediment), acid, and 
sp. gr. 1013. 

When the temperature went down, the urine for a short time changed 
its characters, becoming paler and of reduced density : in one instance, 
it was also copious (39^ ozs.) sweating not having set in ; and in another 
the amount was only 12 ozs., and sweats were reported to be scanty : in 
both cases, the urine was pale or ver}' pale, and had a sp. gr. of only 
1003. 

When the fall was established and whilst it persisted, the urine was 
more or less high-coloured and comparatively dense, sp. gr. 1013 to 
1017, clear or clouded (no sediment) and below the normal amount ; 
before reaction had fully set in, slight variations of aspect were noted in 
the three cases under analysis ; and in all, about the 2nd or 3rd 
day, there was a final brief reversion to the characters of febrile urine, 
in so far that the secretion became scantier, high-coloured and of in- 
creased density, the maximum of 1022 being noted in one instance at 
this time ; bile-pigment abounded, and once the urine showed a 
tendency to decompose early. 

Non-febrile state. — During the day or two following crisis of both 
invasion and first relapse, the urine has been found scanty, high-coloured 
and of increased density (1014) ; it then, whilst still of small amount, 
became pale and of low specific gravity, for a brief period ; again revert- 
ing to a quasi-febrile aspect, without any corresponding change of tem- 
perature. At this time there was no microscopical evidence of renal 
disturbance, only a few crj^stals of uric acid and urates, or of calcium 
oxalate or triple phosphate, with a little squamous epithelium, being 
noted. When rallying became established at near normal state, the 
urine forthwith was plentiful and of low density (1004-8). These data 
are taken from Case IX., and they were generally confirmed by other 
ordinar}' examples of relapsing fever. 

So far as seen, the first relapse was rarely preceded by any change 
in aspect of the urine; the quantities passed on the ist and part of 
2nd days of fever were higher than the preceding mean, showing the 
effect of pyrexia not to be immediate here. In a lad a few hours before 
fever returned the urine was scanty, pale, sp. gr. 1018, clouded and 
slightly ammoniacal (albumen none), though passed only an hour previous 
to examination ; spirilla were already present in the blood. 

The second relapse was deferred and not marked in Case IX. : the 
amount of urine passed seemed to augment for 13 or 14 days after 
the last crisis, and about the 7th and 8th days its density became 
temporarily increased (loio), then reverting to the average (1006) ; and 
during the low and irregular febrile movement ensuing, no change was 
apparent in its aspect. 

In the instance of an adult man (Hindoo) the urine at crisis became 
scanty, only 20 ozs. being found at close of the fall, the amount then 
suddenly rose to 112 ozs. and it soon became even more excessive, so 
large was the daily consumption of water (average 83 ozs.) he voluntarily 
imbibed : after a brief relapse, the daily amount of urine passed became 
less, yet at the end of a fortnight it was 130 ozs., the tint being very pale, 
and specific gravity 1002-1006. 

In the case of an adult Mussulman weaver this excessive dilution 



122 SPIRILLUM FEVER. 

was not noted, though the quantity of urine passed was probably 
above the average ; and the same remark applies to the instance of a 
Mussulman lad, whose urine also showed a tendency to rapid 
decomposition. 

This spontaneously increased flow of urine after fever is noteworthy : 
low specific gravity, diminished acidity and liability to become am- 
moniacal often concurred. 

Special Analyses. — In two ordinary cases of Hindoos, the urine was 
examined twice daily for urea, according to Davy's hydrobromic method 
as modified by Russell and West. The food during fever was the hospital 
milk diet, estimated in the dry state to furnish daily N. 175 '6 grs. and 
C. 2988-43 grs. ; and during the non-febrile state, it was the hospital 
ordinary C. diet, supplying N. 195 grs. and carbon 3430 grs. daily: a 
few ounces of extra bread and rice, or meat and soup, were allowed, 
with small quantities of stimulants as needed. 

Neither patient was seen until after a week's illness at home. In 
the man's case at critical fall of invasion, the urea promptly increased 
to about 500 grains ; for the next ten days, the mean daily amount was 
a little over 200 grs. ; with a brief though sharp relapse lasting part of 
two days, the quantity arose to 430 grs. and thence it declined slowly in 
the course of a fortnight, the daily mean being about 170 grs. : body- 
iveight about 133 lbs. : physique and appetite good. 

The woman's case is that described as No. IX. ; particulars are 
shown in the Table below, and will serve to convey a general view of 
urine-changes. The amount of urea rose at invasion-crisis to 220 grs., 
thence gradually declining till just before the relapse, when the daily 
excretion was only 76 grs. With onset of fever the quantity promptly 
augmented ; it was large during pyrexia and till second day of crisis — 
maximum 226-5 g'^s- j ^.nd it then gradually dechned. Diet during the 
first apyretic interval was the C. above-named, and yet the amount of 
urea was so small as to attract attention : and even if the data are only 
approximatively accurate, this feature is striking. During the first relapse, 
a liberal supply of food was ordered (though I cannot say if all were 
eaten) and the urea became increased ; the patient, however, lost 10 lbs. 
or more than one-eighth of the total body-weight, at this time. There 
occurred a slight but prolonged second relapse (spirillum not seen), 
during which the amount of urea increased at first, though extra articles 
of diet were reduced : this fact shows the influence of even a moderate 
degree of fever. It is also obvious, I think, that a plentiful flow of urine 
corresponds (as might be anticipated) with comparative abundance of 
urea — compare the figures of first and second post-febrile intervals. As 
the patient at last was gaining weight, it seems likely that the urea then 
being eliminated had previously accumulated in the system. There 
were no head-symptoms during the earlier scanty excretion of the urea ; 
but at the second crisis, with some distress, the quantity of urea was 
temporarily diminished. Patient a small, thin woman, with poor 
appetite. 

Chlorine. — The chlorides were precipitated by the addition of a 
weak solution of nitrate of silver, to urine presenting an acid reaction ; 
the proportion of jjrecipitate to volume of urine being then measured 



THE URINE. 



125 



off. No attempt was made to ascertain the actual amount of chlorine 
eliminated. In Case IX., the silver solution produced change of colour 
to deep brown, purple or green, and dense clouding ; precipitate scanty 
on standing : this singular reaction began on second day of relapse, and 
was repeated until critical defervescence when it promptly ceased ; it 
was noted also at the close of invasion-attack on her admission : bile- 
pigment and ordinary albumen were not apparently concerned. In this 

TABLE II. — Mean Daily Data of Urine, F., 35. Body-weight 
ABOUT 75 LBS. Diet mixed. 




instance the chlorides diminished from first to last day of the relapse; 
and in another case, they greatly declined during a long recurrent attack. 
During a brief recurrence of a day and a half, they seemed to increase 
promptly, then greatly declining the day after. At the critical fall of 
both invasion and relapse, the chlorides at first were absent, as a 
rule ; with rallying, they reappeared either slowly or quickly ; e.g. at 
the woman's first crisis gradually, at her second very promptly and in 



124 SPIRILLUM FEVER. 

considerable excess ; also in excess in the slower fall and rebound of 
relapse, in an adult man ; and greatly in excess on first day of crisis 
in a lad. 

The total proportion of chlorides was roughly estimated for Table II. 
(p. 122) by dividing the total daily urine by volume of silver precipitate, 
and so in some other cases, the result being a general concordance in the 
above data, and it appeared that for some days after crisis, there occurred 
an intermittent increase. As observed with urea, a plentiful flow of 
urine generally corresponds with augmented elimination of chlorine. 

Abnormal urinary ingredients. — Bile-acids : from a few observations 
made it seemed that the presence of bile-acids (generally detected) was 
limited to the later part of febrile attacks, with the ensuing fall. Bile- 
pigment was also frequently noted in excess, at the time of crisis ; both 
these indications concurring with known liver-changes. In jaundiced 
patients the above-named ingredients were abundant in the urine, and 
apparently not more so in the casualties. Bile and albumen did not 
necessarily concur. 

Albumen. — In small proportions was not uncommon — perhaps even 
frequent, chiefly at the close of pronounced febrile attacks and a little 
later, the first attack most generally : its amount seldom exceeded ^ vol. 
of urine, and might be less in even severe cases. Almost never was 
there other evidence of acute renal congestion (such as blood-discs and 
tubular casts) : when present, albumen was not necessarily associated 
with marked or peculiar symptoms, and these might exist without its 
being found. The form of albumen precipitable by heat and acids, is 
here alone referred to. I may add that collections of micrococci and 
fine granules have been seen in the urine, which resembled in size and 
form tubular ' casts ' ; these seemed to be only incidental. 

The presence of sugar, as ordinarily tested, was never made clear, 
at any stage of fever. 

Fatal cases. — The aspect of the urine has not been found to differ 
remarkably : there are no complete data respecting the amount of urea : 
albumen, if present, was never strikingly abundant, even when the 
kidneys after death were distinctly implicated ; and it may be absent. 
Granular disease of the kidnies was seen only a few times at autopsy of 
native patients, and on one of these occasions the urine was found to 
contain a small amount of albumen, with a very few hyaline casts ; the 
lesion was evidently chronic. I am not aware of fallacy lurking here, 
if such exist ; but whilst the renal secreting epithelium is clearly liable 
to serious change, the evidence of increased blood-pressure was not, to 
my apprehension, nearly so clear, and in all cases, both surviving and 
f;=ital, the urine-changes in relapsing fever (like the symptoms compar- 
able to the uraemic) have appeared to me singularly slight. 



THE PYREXIA. 12$ 



CHAPTER IV. 

DESCRIPTION OF THE PYREXIA. 

DEFINITIONS. NORMAL TEMPERATURE AND PULSE. ABORTIVE AND 
RELAPSING SERIES : PYREXIA AT SUCCESSIVE STAGES OF ORDINARY 
SPIRILLAR DISEASE : COMPARISONS OF T. AND P. VARIATIONS OF 
PYREXIA AT THE SUCCESSIVE STAGES, AND IN FATAL CASES. 

Temperature-definitions.— By the terms 'rise, and 'decline' or 'fall,' 
is meant elevation above or depression below the normal extremes of 
99° and 97° F. : a ' remission' is a decline not amounting to that com- 
plete suspension of fever, which is expressed by the term ' intermission ' : 
fever is ' continued ' when the remissions do not commonly surpass the 
normal mean range of about i°-5 F. : it becomes 'remittent' when the 
majority of febrile declensions exceed 2° F. ; and it is ' intermittent ' 
whenever the abatement descends to the normal mean of 98° F., or 
below this. 

Duration of febrile attacks. — This must often be arbitrarily reckoned, 
from the difficulty of learning when fever precisely began or ended ; 
and also from the actual duration of pjTexia not being necessarily 
limited by the current account of days. Usually I have included in my 
estimates the first day of decided rise, as well as the day of critical fall. 

Kind of heat. — Whilst the actual temp, attained was probably as high 
amongst Natives as in European patients, yet I rarely noticed, by touch, 
the different modifications of heat usually mentioned in English works 
on Fever : the heat has, however, seemed ' burning ' in children ; and, 
contrarily, the soft integument of some dark-skinned adults has felt to 
me only warm, whilst the thermometer marked as high as 105° F. To 
the cool palm of Native clerks the skin at crises has felt warm, when to 
myself it seemed cold : such differences are readily explained on physi- 
cal grounds. 

Irregular distribution of heat. — In advanced periods of fever, a 
decided difference might be felt by the same observer between the 
temperature of trunk and limbs, especially the hands and feet ; and 
this local variance might be made aware to the patient himself, as I 
happen to know. It is verifiable by the thermometer : vide Case IL, 
at relapse. 

At the critical fall, I have found a temperature in the mouth and 
rectum, hardly above that of the axilla. 

Exaggerated sense of febrile movements. — Several times intelligent 
patients described their primary fever as having been like ' ague ' ; yet 
never that I recollect, was the course seen m hospital of such intermit- 



126 SPIRILLUM FEVER. 

ting character. I have, however, noted in some cases of well-sustained 
pyrexia that chills, and even rigors, were complained of as attending 
mild exacerbations ; and even frequently they were noted at the acme 
of attack, when, to all appearance, the temperature did not rise pro- 
portionately high. Free sweating, also, may attend moderate remissions ; 
and hence, ordinary statements of the sick need cautious interpre- 
tation. 

Another source of fallacy was the history given of long duration of 
fever prior to admission ; 15, 20, or even 30 days have been named by 
patients, when judging by more valid data, such long periods of con- 
tinuous specific pyrexia were in the highest degree unlikely. I have 
not made use of these cases for analysis here, judging them to have 
been instances of relapse with apyretic intervals disregarded, or com- 
plicated by other than specific fever. Such fancied extension of illness 
has been noted in ordinary typhus cases. 

Patients being admitted at different periods of illness, it became 
necessary to consider their state when first seen, before deciding upon 
the intensity of pyrexia ; for not a few were brought either worn out 
by suffering, or so exhausted by want and exposure, that the general 
depression was considerable and but slowly rallied from. 

All temperature observations were made with good English thermo- 
meters, placed in the axilla under required conditions : possibly the 
readings were sometimes within actual limits, but this seems unlikely in 
the warm and uniform climate of Bombay. Cases for illustration were 
selected, and the figures are quoted precisely as entered. 

The pulse reckonings are simultaneous records ; and these I have 
decided to retain, knowing them to be of some value. The rule was to 
take the pulse after an interval of rest, in the recumbent posture. I am 
aware that many circumstances tend to excite and some to depress, the 
heart's action ; and, also, that higher velocities are difficult to ascertain 
with accuracy : whenever practicable, I personally tested exceptional 
instances. The qualities of the pulse are described under a separate 
heading: see the last Chapter. 

It fell within my experience to note that unless the temperature 
readings be carefully and punctually entered, even observers of large ex- 
perience might fail to recognise the peculiarities of true relapsing fever. 
Where malarious fevers are the common type, some additional attention 
is needed for apprehension of new forms of fever ; and I early resolved 
not to make use of any hospital records wanting in clinical essentials. 

Normal Temperature and Pulse of Natives of W. India. — During 
September (a sultry month) observations were made on 6 healthy males 
of ages ranging from 12 to 40 years, in the same manner as those made 
on the sick, and at similar 3-hour intervals throughout the entire day : 
these individuals were hospital servants, clad and fed as usual, each 
being subjected to 2 days' continuous examination. 

Te?nJ>erature. —Considersihle uniformity obtains in actuals, means, 
range and hours of change ; the main result showing a body-heat of the 
scantily clothed native rather below that of the inhabitant of England ; 
but following a similar daily course. The air at Bombay was moist, and 



THE PYREXIA. 1 2/ 

varied very little from a daily mean of 80° F. Hindoos take two meals 
daily, before and after noon. Total observations 102. 

Degrees. — The 8 daily 3-hour means were as follows, beginning with 
the minimum at 4 a.m., and ascending to the maximum at 4 p.m., and 
thence onward through decline at night : — 97°-i8 (min.), 97°*38, 97°"9i, 
98°-! I, 98°-33 (max.), 98°-o5,_ 97°7, 97°-35 : mean range i°-i5 : 
actual maximum 99°"2, actual minimum 96°"6, absolute range 2°-6. The 
mean of all maxima 98°'6 (range 98° to 99°"2), of all minima 97° (range 
96° '6 to 97° '4) ; these data showing but narrow variations. Total daily 
mean t. 97° 78 or about 7° less than the accepted English mean. 

Movements. — Whilst the mean maximum was at 4 p.m., the tendency 
was to somewhat earlier rather than later hours ; and so the minimum 
tended to occur rather before 4 a.m. Twice in 12 observations, a 
temperature equal to maximum was recorded at 10 a.m., or about the 
hour of morning meal ; once the a.m. decline of body-heat was pro- 
longed to the same hour. 

Variations within the limits named, were numerous ; but for the 
purpose in hand, they do not call for record. 

Pulse. — It seems desirable to append some normal data for com- 
parison wdth the sick statistics. Observations 102 ; made on subjects 
at rest in recumbent posture. 

Pulsations per minute. — Inclusive means, beginning at 4 a.m. and 
proceeding at 3-hourly intervals : — 68 (min.), 72, 77, 78, 79 (max. at 4 
P.M.) 78, 72, 68 : the daily mean 74, range 11. Maximum 104, mini- 
mum 46, extreme actual range 58 : mean of maxima 86 (range 104-66), 
of minima 60 (80-54). 

Daily course. — In general, the pulse follows the temperature through- 
out, and at extremes : the slower pulses tend to quicken early in the 
day and soon attain their maximum, whilst the quicker rising at about 
10 A.M. (possibly with food-ingestion) longer maintain their greatest 
velocity, sinking more promptly, but not below the common mean. 

Variations. — Are numerous, and from them it appears that the 
natural velocity (or natural irritability) of the pulse is a datum variable 
in itself, and distinct from contemporary state of body-heat, within 
certain limits. During febrile illness, personal idiosyncrasies were still 
manifest. 

Preliminary general Remarks on febrile Temperature-charts. — 

The intervals of ordinary 7 a.m. and 4 p.m. observations being 9 day- 
hours and 15 at night, temperature movements then occurring remain 
practically unknown ; and such defect is but partially remedied by the 
eight 3-hourly observations, which were all I could attempt. The need 
here of a self-registering apparatus capable of acting for a whole daily 
cycle, is very apparent. 

Upon arranging my data, I find that by the ordinary bi-daily method 
whilst the general course of pyrexia is fairly indicated, yet maxima and 
minima, prolonged exacerbations and minor perturbations of specific 
fever may be overlooked in the lopping off (as it were) contingent on 
this method ; the resulting deficiencies being identical and equally 
evident, in charts of both man and the smaller animal. Thus, of 1 1 



128 SPIRILLUM FEVER. 

brief, isolated paroxysms noted in the monkey, only. 3 were fully shown 
and 8 would have been much reduced or effaced, in bi-daily observa- 
tions : also 7 prolonged attacks would have lost their prompt- beginning, 
smaller day-movements and prolonged night exacerbations, with the 
final perturbation and full degree of critical fall. In the human series, 
a brief night paroxysm would have escaped notice ; also the really 
variable course of an apparently simple one-day paroxysm ; and during 
longer attacks preliminary or abrupt initiatory rises, high night tempera- 
ture, day perturbations, sustained e. elevations, slighter remissions, the 
critical perturbation and full amount of fall, would have been over- 
looked. 

Important as are the above considerations, it is not necessary to dis- 
card the usual Chart-forms, for these must yet compose the bulk of 
clinical data, and do in fact convey valuable information as to the degree 
and duration of specific fever ; their general concordance with preciser 
observations, being shown by their furnishing very similar m. and e. dates 
for most chief febrile phenomena. 

Specific Pyrexia. — Experience in Bombay agreeing with that else- 
where, all ordinary surviving cases of fever may be arranged as follows : 

1. Single attack : Abortive form — probably uncommon. 

2. Recurrent or Relapsing fortii : — 

with I Relapse — the most frequently seen. 

2 Relapses — less frequent. 

3 Relapses — rare. 

4 Relapses — very rare. 

More multiple recurrences were not met with in hospital, except on 
hearsay evidence. 

The distinction of two main forms has been a compulsory one, since 
in a practical sense the fever does or does not return ; and recurrences 
which are not seen by the medical attendant, or not felt or recollected 
by the patient, may be regarded as non-existent. Although I have freely 
allowed that, in a theoretical sense, truly abortive infection may be ex- 
tremely rare (if it ever occur) in man ; yet in the lower animals it seemed 
to be the rule : and, therefore, the clinical discrimination now made, may 
be as correct as it is convenient. 

It is proposed to describe, in order, the several forms of specific 
pyrexia, with their commoner varieties. 

The following Table III. applies to survivors admitted at all stages of 
sickness, casualties being omitted. The entries are given just as heard, 
or as estimated at first view ; separate analyses were afterwards made, 
and these are not found to differ very considerably. 

The Average duration is that of greatest number ; the Mean duration 
is calculated from total actual days divided by total cases, all unknown 
instances being first excluded. As the extremer duration of invasion 
and relapse rests solely on hearsay, most probably the mean is here rather 
over-stated, 



FEBRILE AND NON-FEBRILE STAGES. 



129 



TABLE III. 



-Estimated Number and Duration of Events in ordinary 
Relapsing Fever. 



Days' 
Duration 


Invasion 


I Int. 


I Rel. 


2 Int. 


2 Rel. 


3 Int. 


3 Rel. 


4 Int. 


4 Rel. 

I 
I 


Abort. 


Rel. 


I 

2 
3 

4 
5 
6 

7 
8 

9 
10 
II 
12 
13 
14 
15 
16 

17 
18 

? 


5 
7 

15 
22 
16 

19 
8 

ID 

3 
3 
I 

2 
2 

3 
I 
6 


7 

18 

16 

45 

35 

33 

31 

7 

7 

2 

I 

I 

3 

I 

44 


3 

7 

15 
41 
59 
34 
31 
II 

3 
2 

I 
I 


6 

15 

30 
52 
64 

45 
12 
II 


I 

I 
2 

4 
3 

5 
5 

7 

I 

3 
3 
2 

3 

I 
I 

8 
50 


16 

3 
7 
6 

4 
I 
I 
2 

I 
9 


I 
I 

I 

1 


— 


I 
I 




123 


251 


208 


235 


SO 


5 


5 


2 


2 


Average 


7 


7 


7 


5 


10 


I 
3-1 


— 


— 


— 


— 


Mean . 


8-6 


8-2 7-3 


47 


97 


126 


3 


8 


2-5 



I. Abortive form. — Judging from the mean and average duration of 
demonstrated intervals between first and second attacks of spirillum 
fever, after a period of 10 days a relapse is very unlikely ; and since 
patients could not always be induced to stay in hospital longer than this 
time after the crisis of their first attack, I had to regard all instances of 
non-recurrence within 10 days as examples of the abortive form : in 
practice, a period of 8 days was almost equally valid. Examples of in- 
vasion-attack stated by the sick to be of over 10 days' duration are also 
here excluded, because it was possible they might, through oversight of 
non-specific intervals, include part of the relapse. Thus arranging, I 
found 98 non-recurrent attacks in a total of 411, or a proportion of 23-8 
per cent, which is not inconsiderable : again, a series of 42 well-known 
examples of contagion and inoculation in hospital furnished 9 abortive 
attacks (21 -4 p. c.) or if exclusion be made of 3 instances seen for a less 
time than 16 days after crisis, this number is reduced to 6, equal to 
i4"3 per cent, which gives a ratio still in excess of proportions noted of 
late in Europe.' Of the reality of this form of spirillum fever I had 

1 The older series of cases (1843-6) quoted by Dr. Murchison (I.e. p. 379) gave a pro- 
portion of non-relapses close on 30 per cent., whilst a later series (1869-70) furnishes only 
4'5 percent. ; and a recent author (Dr. Litten, I.e.) mentions a ratio of only 1-5 per cent. 
It is uncertain if these differences point to real variations in the several epidemics concerned, 
or depend rather on n\ethods of reckoning : the numbers quoted in the text do not include 

K 



130 SPIRILLUM FEVER. 

personal proof in my own last attack ; and have shown it to be the 
commonest, if not exclusive, form witnessed in inoculated Quadrumana. 
The insulated or solitary event is a characteristic phenomenon, pre- 
senting a defined and compact febrile attack which is attended with the 
usual symptoms, lasts nearly a week and leaves as abruptly as it came on. 
Practically, no constitutional disturbance preceded, and little or none 
may follow ; and, briefly, there has happened a prolonged febrile paroxysm 
having for its pre-eminent sign an abundant foreign growth in the blood. 
When, as usual amongst paupers, the attack was more severe, it still 
retained its defined character ; and the additional symptoms seemed due 
to personal influences, whereby functional derangements passed into 
organic lesion, or fresh complications arose. As a rule, the longer the 
duration of the attack the more serious its effects — a difference of even 
I, 2 or 3 days being of import here, especially when the prolongation 
was attributable to defervescence by lysis, in place of the prompter critical 
dechne. About a quarter of the total cases were 'mild,' five-sevenths 
'marked' and one-twentieth 'severe.' The monthly majorities were 
entered in September 1877 and May 1878, a divergence which taken in 
combination with the maintained uniformity of character, sufficiently 
shows the slight import of annual and epidemic seasons : nor was a de- 
termining influence apparent of age or sex, personal or social condition, 
or probable source of infection. I did not perceive any fundamental 
difference between these single primary attacks and those followed by 
relapse, and this circumstance might be urged against such distinctions 
as are now attempted ; yet apart from the manifest desirability of some 
clinical division of the subject, it seems highly probable that a real diffe- 
rence does obtain in either parasite or host. Lastly, I note that more 
than one-half the total deaths at Bombay occurred near the close of, or 
immediately after, this first or invading attack, which thus became the 
only one visible to the physician ; and were I to add such fatal cases to 
the surviving total, the proportion of single attacks would become dis- 
tinctly raised. 

2. Relapsmgform. — That the term 'relapse' should be held to mean 
a recurrence of specific pyrexia, seems a natural proposition ; yet much 
discrimination is needed here, for other than specific paroxysms may 
occur during the course of illness, which in common parlance might 
also be called relapses ; and, indeed, probably have been so regarded. 
According to my experience a true recurrent attack is always periodic, 
is les« pronounced than the preceding attack, is essentially free from 
complication with other disease, and is attended with visible blood-con- 
tamination. 

The successive repetitions of fever always tend to become briefer, 
less sustained and longer separated ; their series may be early checked 
or abruptly cut short ; hence it happens that no relapse, whether first, 
second, or third, possesses a constant character ; an abbreviated first 
recurrence, for example, presenting the contour of an ordinary third ; 
and it is impossible to predict the number or severity of relapses from 

instances of mere hearsay evidence. In Finland, Dr. Holsti (see Ziemssen's Cyclop. Sup- 
plement, 1881) noted only one crisis in 20 per cent, of a large number of cases seen during 
1876-7, 



RELAPSING FORM. I3I 

the symptoms which have gone before. The many complexities of this 
subject will, therefore, be obvious ; and, at present, some are still with- 
out a clue. Table III. displays the comparative number and intensity 
(as measured by duration) of successive attacks, according to common 
experience at Bombay. The practical difficulties in accurately esti- 
mating the number of recurrent events in a large series of cases, I found 
to be insuperable.^ 

Relapses occur nearly equally in both sexes, at all ages, and in weak 
and strong subjects ; in the adynamic, typhous, and icteric types of 
fever, they may be quite distinct, or even severe : their frequency 
appeared similar throughout the epidemic. The irregular occurrence of 
relapses under identical outward conditions, was illustrated in the lists 
of individuals affected by contagion in hospital ; and in other compact 
series of cases, where uniformity might have been anticipated. Nor 
does the number of recurrences in each case seen, follow any rule ; 
except that only a single relapse commonly occurs (near 70 p. c. of all 
recurring attacks), with subsequent perturbation too slight for notice or 
practically absent. 

Upon revising my detailed lists of 206 selected instances of Relaps- 
ing fever seen during 1877-78, 1 find 51 (or 24*2 per cent.) were possibly 
second relapses ; but if all forms of febrile paroxysm after close of first 
relapse are to be regarded as representing a second relapse, then the 
number of second recurrences would become nearly as large as that of 
the first. During 1879, I had under care 28 other instances, which 
included 3 examples of proved second relapses, 3 of intercalated 
paroxysms similar to an additional relapse, and 3 of febrile paroxysms 
undetermined in character : then subtracting these 9 cases for com- 
parison, there remained 18 instances, but of these 6 had to be re- 
jected because the patients would leave hospital sooner than 10 days 
after end of first relapse, the mean stay in hospital of the remaining 13 
being 18 days : there was now a total of 22 cases, and if all the above 
febrile events be regarded as relapses, there would be reckoned 41 per 
cent, of second recurrences ; if only the 3 first-named, the proportion 
would be less than 14 p. c, and if the first 6, it would be about 27 p. c. 
Lastly, there was available a series of 31 instances belonging to the con- 
tagion-in-hospital list of cases, which includes 6 examples of second 
relapses, viz. 2 of intercalated paroxysms and 4 of proved recurrences : 
on deducting these 6, of the 25 remaining 16 only were suited for 
analysis, their mean stay in hospital being 20 days after end of first 
relapse, and never less than 10 days : if all the above 6 events be re- 
garded as relapses there would have happened 27 per cent, of second 

1 As illustration of varying opinion in Europe, I may refer to Dr. Murchison's work 
{/.c.) where the proportion of relapsing cases recorded 35 years ago is named at about 70 
p. c, some authors giving a second relapse in 5, 7 or 9*4 per cent, of all recurrences : 
about 10 years ago the relapsing form was estimated at upwards of 95 p, c, in one instance 
second relapses amounting to 8-i p. c. of this : and still more recently Dr. Litten {I.e.) at 
Breslau found 98-5 p, c. of relapses, of which 43-5 were first, 35-5 second, 175 third and 
•75 fourth relapses. At the close of 1877 my own estimate of Indian experience was about 
75 p. c. relapses, of which 62 p. c.were 1 rst, 6 second, 5 third and 2 p. c. fourth ; the subse 
quent data of 1878-79 are embodied in the text. Here there is noticeable, either change 
in disease, or difference of reckoning, with advancing years. Bombay results seemed 
most in accordance with the older Europeans, and experience leads me to add that whilst 
true relapses may be overlooked, there is also a risk of regarding non-specific events in the 
light of veritable recurrences, 

K 2 



132 SPIRILLUM FEVER. 

recurrences in this series, and if only the 4 proved events, the proportion 
becomes 18 per cent. From this summary it appears that the estimate 
of second Relapses, becomes greatly a matter of judgment : for if the 
restrictions adverted to above be adopted, the number of second recur- 
rences could not be said to exceed 20 per cent, of all relapses ; but if 
greater latitude be taken in the use of terms, that number may be 
reckoned considerably higher. 

With regard to third Relapses the proportion of 5 per c. which 
was first mentioned by me may be excessive, since the experience of 
two later years in the epidemic shows third recurrences to have become 
rarer than this in hospital. At present, however, I do not think it pos- 
sible to state their correct proportion, because so few patients could be 
persuaded to stay long enough for adequate observation ; and it yet 
remains to apply strict microscopic blood-tests in these late events. 

I formerly estimated fourth Relapses to happen as frequently as 2 
p. c. of all attacks ; the statement may remain, but there is still required 
a complete scrutiny of the later course of spirillum fever until the 
establishment of convalescence. At least, I was not able to carry out 
this at Bombay with the aid of riper experience, prior to being com- 
pelled by sickness to leave. Judging from personal experience, I think 
that in some instances there would be found a gradually diminishing 
series of more or less periodic febrile paroxysms, devoid of visible 
blood-contamination, as at present detectible ; whilst in other cases, all 
evidence of residual phenomena might be wanting. 

Details of Pyrexia. — Both 3-hour readings and the ordinary M. 
and E. entries, prove that within varying degrees the spirillar pyrexia 
conforms to the normal daily cycle ; and the m. temp, exceeds that of 
same e. only when a nocturnal paroxysm lasts somewhat longer than 
usual, or v/hen a prolonged depression takes place : the m. t. of one 
day exceeds that of the previous e. when a prolonged rise occurs. 
Charts may be further considered as regards the contour lines of daily 
maxima (which indicate the intensity of fever) and of minima (showing 
its sustained character) ; the interval between these lines being the 
extreme range, which is also of clinical interest. I have been accustomed 
to employ the terms level, convex, or depressed, ascending or descend- 
ing with reference to such lines, for expressing the general course of 
pyrexia. 

Mean temperatures have only a limited value, and seldom corre- 
spond to the average or more frequent course ; but as ' means ' are in 
common use, they are added here. 

Pulse reckonings are also given. 

Pyrexial Characters of Invasion. 

Fever begins abruptly : in 33 cases mean t. of m. onset ro3°'2, of e. 
onset 103^ "8. A sudden e. rise of 6°F. has been noted, and probably is 
common : it may occur in two or three hours. The pulse was 113 and 
119 ; it varies considerably and at first may gradually quicken. 



PYREXIA — INVASION ATTACK. 



^33 



TABLE IV. — Mean T. and P. on successive Days throughout. 



Day 


1 


2 


3 


4 


5 


6 


7 


8 


9 




lO 


M. 
E. 


T 


P. 

ti3 

119 


T. 


P. 

124 
119 


T. 


102 '4 
103-6 


P. 

"3 

116 


T 

o~ 
103 
104 


P. 

113 
117 


T. 
o~ 
103 
104 


P. 

118 
123 


T. 


P. 

118 
"7 


T 


102-4 
102-3 


P. 

108 
III 


T. 


P. 

109 


T. 


104- 
£04.5 


P 

Hi 

112 


T. 


P. 

109 
no 


o 
103-7 
103 •£ 



103 

103 '2 



102 '5 
103-8 



103 "4 
103-9 


1O2 

103-7 



p. 

150 
l£0 
MO 
100 


D AY 
123455789 10 


T.C. 
_40 

.39 


^ M E IM E. M E|M e 

10+ 1 i 


M EJIVI E 

«1 . 


M . E 


M E 


M E 

A 


M , E 


103 y \-\ /^N 


v^A 




r 


\ 


102 ,.^.^ ;'' 


■^1 ■ 


w 






v 


101° '-' ! i^-^^r^'" 


' !^'^ 


\-^ 


^ 


■■^.--^ 




100 1 1 


.• i 


V 









Starting at +103° pyrexia declines on the second day or till third 
morning, when a prolonged rise begins extending to seventh day, or 
usual date of crisis : in prolonged cases, another brief elevation takes 
place. Individual charts show the contour of maxima to be tolerably 
level ; whilst that of minima varying more descends, the daily range 
rather increasing to the last. The pulse, in general, follows the tempera- 
ture ; but quickens more gradually at first, and towards the end does 
not so freely rise. 

The general elevation of t. varies in different cases throughout the 
attack : in children and women it was seldom very high, nor was it con- 
siderable in cases of an asthenic or typhus character, which were seen 
amongst weavers. The pulse, on the contrary, is apt to be quicker in 
all three instances. In robust male individuals, there might be a high 
temp, with a pulse hardly so quick as in the mean. 

Extre7?ie Temperatures and Range. — In the typical series under 
analysis, the maximum t. noted was 105° '8 on the sixth evening, and 
1 05° -4 on the foUowing morning ; and a somewhat similar connection was 
noted on the fourth and fifth days : these tendencies possibly indicating 
natural periods in the course of the attack, and fresh accretions, more 
clearly than in some other specific fevers. At such times, the normal 
daily cycle becomes temporarily obliterated. In exceptional moments 
such as the critical perturbation, the t. may rise above 107°, and doubt- 
less the actual maxima were often overlooked. In monkeys, however, 
the t. does not rise higher, though starting from a more elevated normal 
level. 

Minimum t. — The tendency of the spirillum fever in man to decline 
on the 7th day was shown by the low minima of 99° -8 both m. and e. 
occasionally noted : these figures have been retained as being above 
normal, but it is proper to remark that the crisis followed on. In another 
table, the data pertaining to known periods of the invasion will be 
furnished ; here allusion is made to the mean t. found upon any days 



134 



SPIRILLUM FEVER. 



(excluding the fall) in attacks of all durations. A similar but less marked 
tendency to droop was observed on the third day, and again at the end 
of attacks prolonged to the tenth day. 

Pulse. — The quickest mean p. was found on the second morning 
(124) and fifth evening (123) : the slowest on the seventh day m. and e. 
(108 and III). 

Ranges. — The greatest mean daily range of t. is ordinarily not quite 
2° F. ; of p. about 14 per minute : the daily range is greatest at begin- 
ning and towards end, and least about midway. The febrile state whilst 
it lasts is well sustained, and in this respect resembles the fever sympto- 
matic of acute inflammatory lesion, or typhus, rather than that of re- 
mittents, hectic or enteric fever. The following figures were derived 
from four mild cases of moderate duration. 

TABLE V. — Mean T. and Range throughout Invasion. 



Day 


I 


2 


3 


4 


5 


6 


7 


M. 

E. 



103-2 



102-5 
104- 




102-7 
103-4 




102-4 
103-2 


I02- 

103-7 



102-5 
103-5 


96-2 


Range 


47 


I -5 


•7 


-8 


1-7 


I- 


7-3 



The range between extremes of temperature was greatest on the 
seventh day, both m. and e. ( + s°F.) ; or more generally from sixth to 
eighth days inclusive ; and least, at first and last ( + 2°) : on the fourth 
day this range was less (2° -6) than on either third or fifth : the m. t. had 
a rather wider range than the e. t, except on first and eighth days. 

Extreme variations of pulse. — These could be adequately illustrated 
through the means only of individual cases ; but in the larger series it 
was noticeable that the maximum frequency of pulse both morning and 
evening was entered on the second day (144 m. and 134 e.) and again 
on the sixth (136 m. and 142 e.), whilst the common minimum occurred 
on the fourth day (99 and 90). The morning p., particularly, tends to 
decline at the close of prolonged attacks : at initiation, the pulse range 
was 96-120 for morning initiation, and 104-124 for evening onset. 

The above memoranda being based on bi-daily observations, I wish 
it were possible to control and expand them by means of 3-hourIy read- 
ings ; but there is not with me a complete series of the minuter records for 
man. Some details are, however, given under the heading of ist Relapse, 
and these may not differ fundamentally from those of the invasion. 

Having now discussed the data in their collective form, it is desirable 
to allude to them in connection with main epochs of the invasion ; and 
IS regards the single or recurring forms of the fever. 

The mean initial t. of 5 ordinary cases of abortive form were io3°-7 
(m.)and 104° (e.): of 5 cases of the relapsing form io2°-6 and io3°-5; the 
pulse in both series being nearly the same, viz. 110-117 (m.) and 120 (e.). 
Nothwithstanding the higher mean t. at initiation of the abortive series, 
there was not enough uniformity in particular instances, to warrant a 
prognosis of character and duration of the illness being inferred from 
this datum. 



PYREXIA— INVASION ATTACK. 



135 



Later course and termination. — In another set of 24 ordinary cases 
not attended with complications, of which 14 were relapsing and 10 non- 
relapsing, the mean t. and p. of the invasion -attack, so far as seen, were 
as follows : 



TABLE VI. — Abortive Series of varying Duration. 



Fall 


Days prior to Fall 


M. 

E. 


T. 


P. 


T. 


P. 


T. 


P. 


T. 


P. 


T. 


p. j T. 


p. 



96 


93 



103 
104 


120 
130 


103-2 
104 


124 
127 


103 
104 


IIO 

120 


1 02 -8 

103-2 


126 
109 



102-5 
104*2 


106 

"5 



Relapsing Series of varying Duration. 



Fall 


Days prior to Fall 


M. 

E. 


T. 


P. 


T. 


P. 


T. 


P- 


T. 


P. 


T. 


p. 


T. 


P. 



96- 

95-6 


85 
81 



102 -6 
104 


1X2 

"5 


103 
1037 


"3 

118 


102-5 
104 


116 

120 


10 -6 

104 


119 

121 



103 
10^ 


104 

123 



When the m. fall was prolonged till e., the t. of the previous e. was 1° 
less in both series : the p. declined most where fall was prolonged. 

It is probable that some of the indicated differences between the 
above two series, have a foundation in reality : e.g. that the non-recur- 
ring attack (which tends to be the briefer) has a somewhat higher and 
more sustained t, and a more prompt critical fall ; with the pulse slower 
to rise, but maintained at the end. 

Contour of Invasion. — In upwards of one-third of 46 cases, the chart 
contour line is ahnost level, not seldom it somewhat descends, and less 
frequently, it is either convex or ascending; a mid- descent is rare and a 
decidedly wavy contour is quite uncommon. 

The type of fever was in two-thirds of all cases of a continued 
character, daily range of temperature not exceeding i°-2°F. : in the 
remaining one-third it was distinctly remittent, i.e. the daily range was 
over 2°F. : the intermittent type in which the temperature at some time 
of the day descends to 99° was not seen in this series, and elsewhere it 
was extremely rare ; so much so, indeed, that I remember seeing only 
2 or 3 instances during the entire epidemic, and these were complicated 
with dysentery. 

Of these bi- daily series a perceptible perttirbatio critica was absent in 
two-thirds, and in the remaining third, it seemed comparatively mild ; it 
is well known, however, that the final exacerbation may escape recog- 
nition in the absence of more frequent readings. 

Contour lines of the pulse are before me, showing its tendency to 
follow the t. both throughout and in diurnal changes ; but the sequence 
is an interrupted one : thus, on the first day the pulse does not rise so 
promptly as the t, and on the second day it still rises for a time (then 
attaining its maximum), soon however to follow the t., which has fallen 
somewhat : on the third, p. and t. may be said to correspond, next day 



136 " SPIRILLUM FEVER. 

the t. rises and the p. also, with a promptitude which carries it to its 
second maximum on e. of fifth day ; thence it descends rather slowly to 
about the level it had on the first morning. Now there occurs either 
the crisis or a further considerable rise of t. prolonging the attack to the 
tenth or eleventh day, but the pulse does not ascend proportionaLely 
after the close of a week's fever. 

As regards the differences between invasions which are followed by 
a relapse and those which stand alone, what was elicited is as follows : — 
the abortive attack tends to be highest at first (with no final rise) ; 
seldomer it is level and rarely convex in contour ; only exceptionally 
do distinct remissions occur, but a disposition to mid-descent may 
appear ; the J>erturbatio critica was more or less indicated in nearly half 
of 42 cases. The primary event which was followed by a recurrence, 
differs somewhat in oftener presenting a more level summit ; the ten- 
dency to decline midway is frequently noted, and the final exacerbation 
may be more marked ; the type of fever is more apt to be distinctly 
remitting and, on the whole, there is a wider variety in its contour : the 
intermittent type was extremely rare (38 cases analysed). 

Such is the summary of repeated attempts to elicit a normal or 
fundamental form of the spirillum fever, which ci priori might be 
thought to exist in so specific an affection ; yet I cannot say that the 
results have been decisive : it is true there are manifest variations in 
the abundance of the attendant blood-parasite, yet here again I have 
failed to connect the phenomena which seemed probable. Enough 
concordance appears, however, to permit of an accurate idea being 
gained of the clinical course of the first and chief febrile event ; and 
this I did not myself possess, until the present analysis was undertaken. 

Pulse. — In the two chief forms of invading spirillar attack, the 
following differences are noticeable : — abortive form ; fever descending, 
remittent, the p. rises promptly to its first ma\imum, then falling to its 
minimum on the third morning, it ascends and maintains a moderate 
level, till finally rising at the close to reach its maximum on the fifth or 
sixth evening, in the shorter attacks. Recurring form : the pulse does 
not rise and fall so promptly at first ; its mid-course is tolerably uniform; 
at the end it quickly rises and more slowly descends, not again recover- 
ing, even in prolonged attacks. The maxima and minima of p. and t. 
nearly correspond in date to the ist and 5th evening, and the 3rd, and 6th, 
and 7th morning, respectively: this statement being of general application. 

Ending of the Invasion. — With rare exceptions this occurs by way 
of crisis, and the fall of temperature is not only abrupt but excessive ; 
much surpassing the initial rise (itself equally prompt), and not being 
strictly accordant with the previous elevation and duration of fever. The 
pulse hardly participates in this disproportionate decline of body-heat. 
As the crisis offers a uniformity of character equal to that of the febrile 
state, it may be regarded as an essential feature of the entire specific 
manifestation. 

Pertiirbatio Critica. — There are many degrees of pyrexial disturbance 
to be seen on the last day of fever, and the most prominent of these 
assume the form of a distinct febrile exacerbation, preceded by chills, 
pronounced in intensity, brief in duration, and directly initiating the 



I^YREXIA — CRISIS. 137 

critical fall with copious sweats. Although there is reason to regard 
this final acme as being common, if not to some extent invariable ; yet 
in the ordinary clinical charts, its occurrence seems unusual. Thus, a 
distinct critical exacerbation was not seen in more than lo p.c. of all 
invasions ; and as regards the less pronounced febrile disturbances all 
that can be said is, that in somewhat less than half the cases the tempe- 
rature on the last evening rose from ^° to i°, seldom more, with no 
particular symptoms and but little exaggeration of the febrile stress. 
Such exaggerations of the normal e. rise when final are not necessarily 
followed by a fall descending below the critical mean (96°), nor after a 
well-marked perturbatio critica does the t. inordinately subside, in 
general ; on the contrary in six instances the mean t. was 96° -3 ; 
maximum 97°'4, minimum 95°"4- It may, however, happen that after 
a prominent final exacerbation the fall is very considerable, and these 
are the instances which furnish the most striking figures in illustration 
of the range at crisis. 

An example of the progress of pyrexia is the following : — 

Case XXVI. — An adult ward-servant, in previous good health, contracted 
relapsing fever in hospital, and came under special clinical observation. The 
invasion was pronounced and attended witli the usual symptoms ; on the sixth and 
last day, the t. at 7 A.M. was l02''-5 : p. 120, at noon it had risen to 104^, at two 
P.M. 105°, at four P.M. io5°-5 : p. 130; at five P.M. the t. was io7°-2, pulse 134, 
and at six p.m. the acme of io7°'5 (P- '32) was attained : at seven p.m. the t. had 
sunk to 103° '2 and there was copious sweating, at half-past seven the t. was 101° "4, 
at eight the same, at nine loi°*2, at eleven ioo°*8 and at midnight I00°'4; at six 
A.M. of the following day the t. was 99° ; a slight rebound followed, prior to min. t. 
of 97° -8, p. 80. J. J. Hospital. 

In my own late brief single attack the fever distinctly culminated 
during the final night of 5-6 day, the temp, after constant cold sponging 
not going below 105° "2, p. 120 : it declined at early m., being 103° (p. 
114) at 7 A.M. but rising shortly to io4°-4 (p. 118), thenceforward de- 
clined during the day. The pulse, as usual, followed the temp, but 
somewhat in arrear ; quickening to 120 at 11.30 a.m. when the body- 
heat had already begun to decline. For comparison with critical 
phenomena at first relapse, see Case IX., Chapter III. 

Crisis. Date. — In a series of 60 cases happening at all periods of 
the epidemic, crisis occurred on the 7th day twelve times, 8th day eleven 
times, 9th day nine times, 6th day eight times, on the loth and nth days 
six times each, 4th day four times, on the 5th day thrice and on the 12th 
day once. As much of this evidence regarding dates was hearsay, and 
patients probably rather overstated the duration of their illness, I will 
here mention separately the day of crisis as witnessed in cases of disease 
acquired in hospital : amongst sick patients it was in the mean 6 days 
(extremes 4 and 7), amongst students 7-5 days (extremes 6 and 8) and 
amongst servants 7-6 days (extremes 6 and 9) : in the four last instances 
of contagion at the G. T. Hospital the day was the 7th thrice, and 
probably the 8th once. The predominance, therefore, of the seventh 
day as that upon which the crisis, chiefly or wholly, has been seen, is 
sufficiently apparent ; next in frequency follows the eighth, sixth or 
ninth : I have never witnessed throughout any attack lasting ten days 
or more, but have the full records of a few of only four or five days' 



138 SPIRILLUM FEVER. 

duration, so that it is certain the crisis may supervene at periods varying 
from four to nine days. 

As regards period of day at which the complete fall was noted, of 79 
charts 53 showed the morning, and 26 the evening ; or in the proportion 
of f and ^ respectively : whence appears a tendency of the spirillum 
fever to subside between the hours of 4 p.m. and 7 a.m. The specific 
character of spirillum fever is, however, indicated by the fact of about 
-^ of crises occurring mainly or wholly during the daytime, when the 
normal temp, habitually rises and reaches its maximum ; this propor- 
tion, indeed, becoming larger if the 24 hours be physiologically divided 
into periods of normal elevation and depression. 

Rate of critical decline of temperature at Invasion. — Bi-daily read- 
ings show that, as a rule, subsidence of fever was completed in i day, 
and commonly within 12 hours ; estimates depending partly upon the 
method of reckoning, when, as often happened, the fall was not strictly 
continuous. The main decline may not, however, occupy more than 
3-4 hours, or occasionally less ; e.g. in cases specially observed there 
has been seen a fall of 6° -8 in 3 hours, 5° '4 in 2 hours, and 4° '3 in i 
hour : the slower descent before or after the main one, is a singular 
phenomenon which I failed to comprehend ; and analogous to this is 
the persistent depression sometimes seen at end of crisis. The mean 
rate throughout in eight detailed cases was about 8° in 11 hours, the 
observed extremes being 4° "3 and "2° per hour : commonly the longest 
fall occupied most time, e.g. 12 hours for 9°-io° ; and the shorter a less 
time, e.g. 7 hours for 7°. In 3 of these cases the decHne was most 
rapid at its beginning, in 5 it was quickest at middle or towards the 
end ; from my own case it seems that with free sweating the cooling 
may t e hastened, but on other occasions this connection was not stated 
or implied. It is noteworthy that the rate of main fall was decidedly 
quicker in day crises than in night crises, the respective means being 
6° '4 in 4 hours and 7° "8 in 9 hours ; which is a datum hardly to be 
anticipated, on the supposition that the decline of febrile temp, would 
naturally be hastened when concurrent with normal decline of body- 
heat. As regards the final lingering of critical subsidence, I noted in 
32 early cases that about one-fourth of the preponderance of m. mimima 
was due to prolongation of the fall in 7 th m. until m. of 8th day ; the 
occurrence being almost limited to these particular dates, which were 
also the commonest entered. Much variety obtains at the lowest 
turning-point of crisis, rallying being prompt, delayed or intermitting 
(as it were) in very various degrees. 

Form. — As represented in ordinary charts the crisis assumes one of 
three forms, namely either an uninterrupted line of descent, which is 
the most frequent ; or a descent rapid at first and towards the close 
sower or delineated as a sloping line, which is not unusual ; and, lastly, 
as a line oblique at first and finally vertical. The last form is so rarely 
expressed that it might be regarded as hypothetical, yet an approach to 
its character was noticeable in the cases where for the last two or three 
days of the febrile state the t. had perceptibly declined from its acme, 
to fall suddenly to an extent diminished by so much as it had already 
been gradually reduced. Occasionally, too, the t. has been low and 
stationary on ihe last day of fever, not rising as usual at evening. I 



PYREXIA— CRISIS. 



139 



mention these instances as exceptional, and therefore of interest as 
indicating what features are essential to the fever, and what may be 
modified without its characteristics being annulled ; already it will be 
apparent that in such cases as those last mentioned or even the earlier 
ones, should the decline be further interrupted by subsidiary daily 
febrile paroxysms, it will come to gradually assume the character of 
* lysis. ' 

Degree of critical fall. — The minimal points actually recorded must 
be regarded as only approximate. As the figures stand, I find that at 
the height of the epidemic there were amongst 18 cases of Hindus, 4 in 
which 94°-95° (actual minimum 94° '5) 6 in which 95°-96°, 6 in which 
96°-98°and 2 cases in which temp, of 98°+ have severally been entered 
as the lowest points of the fall : in a later series of 18 cases amongst 
Mussulman weavers, the same point was only once entered so low as 
95° -6, and only twice was as low as 96°-97°, the remaining instances 
showing usually about 97°, thrice 98° and thrice 99°, as the minimum, 
all in uncomplicated instances. Such less degree of fall accompanied 
less pronounced high temperatures, and both features seemed to belong 
to the modified (possibly typhus) type of fever which prevailed most 
amongst the weavers. 

The following table pertains to the same series of cases as the tabular 
statement of mean t. and p. during pyrexia, which was quoted above. 

TABLE VII.— Mean T. and P. on successive Critical Days, with number 
OF M. and E. minima. 

























— 




1 


M 
E 


4 


5 


6 


7 completed 


8 


9 


10 n 


T. 



97-1 
97-9 


p 

97 
96 


T. 


96-4 

95-6 


p. 
92 


T. ' P. 

1 
96-1 80 

97-2 90 


T. P. 
967 87 

97-6 91 


T. 

96-8 


p. 
79 


T. IP. 

j 

96-5 80 
94-5 — 


T, 



97*3 


P. 


T. 



97 -S 


p. T. 

1 ° 
— 96-3 
8096-8 


P. 

82 


M 
E 


2 
2 


2 

I 


3 
2 


2 

5 


4 



6 
I 




2 




2 


2 

I 



In general with a prolonged decline the t. sank to 96°, or even 
lower ; but the minimum falls were, even with an abrupt and direct 
decline, when the t. subsided within, at most, as many hours as there 
were degrees of subsidence; for example, 10, 11 or 12. Reckoning 
the departures from a normal level of 98°, it will be seen that while the 
ascent of t. at the initiation of attark maybe estimated at 5° or 5° -5, 
the descent at the crisis exceeds this figure by 2° or 3°; which represent 
an amount of depression not met with in other continued fevers. The 
less degree of fall to 98° or 99"" in cases otherwise typical, has, however, 
undoubtedly sometimes occuired ; and I did not detect extreme critical 
depression in the sick monkey. 

Respecting observed extreme ranges, the data are only approximate, 
but in such instances there appeared no reason to reject the estimated 
record of 94° '5 or 94°', or less : the following case occurred at the J. J. 
Hospital in Feb. 1878 : — 



140 SPIRILLUM FEVER. 

Case XXVII. — F., 40, Mussulman, immigrant, widow, not emaciated, was ad- 
mitted at near close of invasion, with usual symptoms and considerable splenic en- 
largement : on 7th or last day of fever, e. t. 104°, p. 128 : day of crisis, m. t. 96°-4, 
p. 72, e. t. 93° "6, p. 68, and next day of prolonged depression, m. t. 93° (estimate), 
p. 72, she was then delirious ; e. t. 93'''4, p. 72 ; the extreme depression and active 
delirium slowly passed away during the next three days, and in six more she was 
discharged convalescent. The mercury sank below the register. 

Once the recorded descent of temperature amounted to 12° F. ; a 
prompt decline of 10°, or even 11°, was not very uncommon ; these 
deeper depressions depended partly upon the height of temp, at the 
previous acme, and the deepest were those in which there happened a 
prominent perturbatio critica before an excessive critical fall ; such con- 
junction was comparatively rare. Supposing, however, a concurrence 
in the same individual of the two extremes known to me (viz. of 108° -4 
and 93°), a descent of 15° F. would have been indicated. 

Pulse at crisis. — Here the chief notable feature is that the rapidity 
of the pulse does not decline in amount corresponding with the fall of 
temperature : this fact was invariable, and it is well worthy of attention. 
Already in the course of invasion seizures it was observed that the pulse 
did not rise with the pyrexia towards its end \ and this want of con- 
cordance, indicating a lagging behind of the circulation, became still 
more apparent at the crisis. The mean p. at fall was shown in Table VII., 
from which it appears that at crises occurring on the 7th day and pro- 
longed to the 8th m., the pulse sank to 79 beats per minute with a mean 
t. of 96° "8 ; in the earlier crises it might be quicker, in the later of equal 
velocity or possibly lower with temperatures higher and lower respec- 
tively. In the main, the pulse follows the temperature and hardly shows 
a greater tendency to variation, when individual cases are separately 
considered : idiosyncratic influences, however, remain, and at the crisis, 
as previously, in children, women and cases showing a low type of fever, 
the pulse often continues even high. Experience at Bombay seems to 
have been somewhat unusual, as regards the tendency of the pulse to 
remain frequent at crisis ; nor were the excessive slowings sometimes 
recorded in Europe so likely to be met with there. ^ The minimum p. 
in the collected series, was 60 in a case (abortive fever) where the circu- 
lation was unusually slow throughout the entire attack ; the maximum 
p. noted in the crisis was 112 (quick throughout) in an abortive attack ; 
and 120 in one of the relapsing form, characterised in other periods by 
an unusually quick pulse. 

In crisis prolonged from morning till evening, the pulse continues to 
sink with the t. in most instances, and may become so slow as 70 per 
m. : sometimes it happens (one-fifth of cases) that it does not subside 
after the main fall, and, as a rare event, it has been found to rise a few 
beats after the main decline ; although in both these instances the t. 
still further subsided to a slight extent. As a rule, with moderate fall 
of temp., there con'^urs a moderate declension of pulse ; and with pro- 
nounced fall {e.g. 10° or 11°) the pulse becomes much slower {e.g. by 60 
or 70 beats per minute). 

' Dr. Frantzel at Berlin, 1868-9, stated that the pulse sinks to less than 60 per minute, 
as a rule ; is often less than 50, and sometimes only 40 : it becomes 40 or 60 beats slower 
than before, and once was noted to decline 80 beats at crisis. Virch. Archiv. vol. xlix. i8;o. 



PYREXIA — LYSIS. 



141 



The pyrexia! phenomena of crisis were almost identical in first at- 
tacks which were abortive, and in those which relapsed ; being only 
somewhat less prompt in the recurrent form. 

Lysis. — Towards the close of a primary attack of spirillum fever, the 
pyrexia occasionally assumes a distinctly remittent character, in which 
the morning t. is as 1 w as 101° or 100° whilst the e. t. rises to 102° or 
103° or more, till the crisis arrives, when the attack ends for good : 
sometimes the t. on the last evening was no more than 101°. Another 
set of cases seen in about one-tenth of all, was that in which after the 
beginning of the crisis, the further descent of temperature was effected 
gradually, or by a series of short daily paroxysms, exacerbating at even- 
ing and diminishing in intensity, until the normal level was reached in 
the course of two or three days. 

In both these modified forms of crisis the final minimum of t. was 
generally not liwer than 97° or 96°"5, the pulse being quick as often as 
5I0W. In a 'ast series, much more rare than the others, but merging at 
points identical in all, this critical termination became altogether undis- 
tinguishable, and true lysis was established. 

This I have witnessed in 9 or 10 instances only, and almost always 
in invasion-attacks. Then the last 2, 3 or 4 days of continuous high 
pyrexia were replaced by a corresponding series of daily paroxysms, 
commonly of increasingly remittent character ; which commencing 
gradually or abruptly and oftenest at morning, promptly became inter- 
mittent, and with declining evening exacerbation then subsided to the 
normal level, or to 1° or 2° below it. This lytical termination varies in 
duration and intensity : when watched throughout, the mean duration 
of the invasion-attack was not apparently prolonged, only its last three 
days being thus modified, and there was a slight tendency to rebound 
at the end. A relapse was the rule, and it, too, modified at the close. 
The mean t. and p. in 6 early instances are shown in the following 
table : others seen afterwards fairly concord, and it is worth noting that 
of the 7 patients whose cases are specially considered, 5 were females : 



TABLE VIII. — Mean Temperature and Pulse in Lysis. 



Day 


I 


2 


3 


4 


5 


6 


7 


T. 


P. 


T. 


P. 


T. 


p. 


T. 


|P- 


T. 


p. 


T. 


p. 


T. 


P. 


M 
E 



102-3 
1027 


125 



100-9 

loi- 


103 
104 




99-4 
98-6 


100 
97 


98-9 

97-6 


96 
100 



97-9 

97- 


92 
72 



96-7 

97- 


96 
100 



96-6 


108 



The minimum of t. and p. was reached on the 4th day of lysis (about 
the 7 th day of the attack) three times, and once on the 5 th, 6th and 
7th days of descent, when it would seem that the fever was prolonged. 
The variations of pulse here noted at the close were due to particular 
cases, and those of t, were partly so ; it being noteworthy that the morn- 
ing t. and even. p. were highest on the three earlier days of lysis, corre- 
sponding to the terminal ones of the ordinary invasion seizure. 



142 SPIRILLUM FEVER. 

When the slow fall lasted for 5, 6 or 7 days and a relapse followed, 
it a'^nearrd that the first apyretic interval was encroached upon : in one 
instance the entire attack extended over 14 days, and there was no re- 
currence. 

I will add that though it might be supposed subsidence of fever by 
this mode indicates mildness of the attack, yet such is not commonly 
the case ; and all the above six cases were severer than usual in exhibit- 
ing symptoms approaching those of continued, i.e. typhus-like fever. 

Lysis at close of a first relapse was very rarely seen : a few well- 
marked instances, however, came under notice, and these were attended 
with much suffering and prostration. See Chapter III. 

Duration of the Invasion-attack. — This has been reckoned from the 
first onset of fever until the main fall at crisis inclusive ; and the data 
are derived from 341 earlier cases seen at the hospitals. In by far the 
majority of instances the statements of patients was the only authority 
for dates, and often, at least, might be depended upon, for the onset of 
fever is generally so definite as to be unmistakeable ; error, how- 
ever, might occur in two directions, namely by ante-dating the attack 
when premonitory symptoms were included, or by post-dating the real 
onset by reckoning from the day when the patient had to lay up. Such op- 
posed calculations would be mutually antagonistic, and that the approxi- 
mately true duration of the attack has been elicited, seems to be shown 
by the remarkable concordance of all the figures, when duly checked 
and compared. For this purpose, the contagion series embracing the 
cases of students, servants and patients infected whilst under observa- 
tion, was available at both hospitals ; and the result has been an ap- 
parent uniformity of duration in the initial spirillum fever of man not 
to be met with in other specific pyrexias, with the exception of the 
vaccinal, which, like the spirillar, is due to a contagium capable of being 
transferred at will from one individual directly to another. The limits 
of variation in the human events are, however, much narrower than 
those observed in the artificially induced pyrexia amongst quadrumana. 
Mean duration 7-5 days, average 7 days, range 4 to 13 days : with re- 
spect to the last item I should observe that the shorter period was seen, 
but the longer has not been actually witnessed ; the actual number in 
each extreme was only two or three. It is also worthy of note that in 
13 of 26 sick persons attacked in hospital furnishing accurate data, the 
duration of attack was, in the mean, at least a day shorter than in all 
other instances, with an average of 5 -5 and a range of 4 to 7 days : 
whence it might be inferred that a weakened or diseased state of the 
body interferes with the full development of the pyrexial agent, and that 
a perfectly healthy condition would be favourable thereto. The clinical 
interest here rests upon the assumption that duration is a measure of 
intensity ; and this last may be also connected with the activity of con- 
tagium, as well as with the state of the body its recipient. The term 
day here stands for a period of 24 hours. 

Marking early the prominent distinction between febrile seizures 
which occur only once, and those which are repeated ; I have sought to 
ascertain whether or not their respective duration differs, and find there 
is practically no distinction to be made here. On comparing closely 
two selected scries of cases, the only difference I note is u tendency of 



PYREXIA — FIRST INTERVAL. 1 43 

the relapsing invasion to last somewhat the longer ; and it was amongst 
the Mussulman weavers that this tendency prevailed most, or wholly ; 
the Hindoo famine-immigrant not showing it. 

First Apyretic period.- — Except when a rebound immediately follows 
the critical fall, the temperature is low for two or three days, according to 
the promptness of general reaction : and it is rare to find the normal t. 
at once and permanently established. The pulse at first retains the slight 
preternormal frequency it had at the fall. Subsequently there is a gradual 
ascent of the t, most marked at first, until about the 5th or 6th day, 
when the normal level of 98° '5 is attained, and thence a level course is 
preserved, until the day of relapse. Amongst instances of deferred re- 
lapse there may often be detected a perturbation of t. on the 7th day, as 
indicated by slight rise at evening, or a morning decline, with possibly some 
headache or other slight symptom ; and not seldom a day or two before 
the relapse even when not deferred, there occurs a mild depression of 
t. which I have known to correspond with the initiatory appearance of the 
blood-parasite : such perturbations do not exceed in range 1° or 2°, or 
the limits of normal variation, and are liable to be overlooked. This is 
also the case with a similar phenomenon, usually rather more distinct, 
which takes place about the same date as the so-called abortive attacks; 
and in them may indicate a suppressed tendency to relapse. The 
ordinary charts may also show other minor degrees of pyrexial agita- 
tion, amounting in the end to a recognisable second outbreak, consist- 
ing of brief daily paroxysms, single or repeated and blended : so that 
whilst in general it may be said the relapse is either present or absent, 
yet in particular, there are milder degrees of recurrence whose import 
will be differently estimated. 

The Pulse. — Whilst thet. gradually ascends during this first interval, 
the pulse is found to decline in frequency, and their respective contours, 
as displayed in the chart, commonly cross on the 2nd or 3rd day, that 
of the pulse continuing to decline in a more or less gradual manner 
until the 5th, 6th or 7th day ; and then promptly rising to its normal 
velocity just before setting in of the relapse. It concurs with the t. in 
sub-latent pyrexial perturbations, and may by its own changes of either 
increased or diminished frequency, more clearly or alone indicate their 
occurrence. As these slighter disturbances do not always correspond 
exactly in date, they do not necessarily appear in outlines of means, and 
are best studied in individual instances. Non-periodic changes of p. 
or t. have a different import, and with due care might generally be 
discriminated. In consequence of its peculiar course, the m. pulse 
bears a high relation to that of the evening, and for a time is quicker 
on the same day. The sinking of the pulse after specific fever may 
continue until the day of relapse, and in abortive attacks it may persist 
for many days, its actual degree being sometimes striking. Similar 
decline occurs after malarious fever, but is not so pronounced. 



144 



SPIRILLUM FEVER. 



TABLE IX.— Mean Temperature and Pulse during First Interval. 

17 Cases. 



Day 

M. 
E. 


I 


2 


3 


4 s 


6 


7 8 


9 10 


T. 

96°9 
97-4 


P. 

80 
84 


T. P. 

° 1 

97-5 78 
97-6 80 


T. 


97-4 
97-9 


P. 
76 

77 


T. 


97-4 
98-1 


P. T. 

7398°-! 
7598-1 


P. 

73 
76 


T. 

98- 
98-3 


P. 
72 

73 


T. P. 

97°9 72 
98-3,73 


T. P. T. 

98°2 71 9S°2 

987 7698-2 


P. 

70 
78 


T. 

98°2 
98-6 


P. 

75 

82 






The temperature is lowest on first day after crisis : the normal daily 
course is maintained in that the e. t is highest, with rare exceptions : 
always the temperature rises towards the end by about 1° ; its mean 
level is below the normal, showing the generally depressed condition 
which follows the pyrexial attack, and sometimes in the weak and old 
this was strongly indicated. 

The pulse is highest at first, and that of the m. may be quickest, its 
mean range is about fifteen beats ; its general level probably over 
rather than under the normal. 

This apyretic period is liable, at its commencement, to a smart 
febrile rebound following the crisis, which seems to me mainly func- 
tional : it is also liable to interruption from many complications, usually 
arising soon after the crisis, and only occasionally does it offer the strictly 
neutral features of simple convalescence. There are some differences 
as regards the two forms of invasion, but these were neither consider- 
able nor uniform; and the great similarity of phenomena in non-relapsing 
and relapsing attacks, appears to me well worthy of notice. 

Amongst Mussulmans was found a subdued type of the spirillum 
fever (the blood-parasite meanwhile abounding), marked by shortened 
crisis but persistent depression, and the mean level of t. in place of 
steadily ascending during the apyretic interval, rose only at first (98° -4) 
and from the second day to the last slowly declined till the day of 
relapse (97°). The pulse also while quicker at first (88) than in other 
series, did not descend, as in them, so as in the chart to cross the line 
of t. ; but following the t. very gradually declined till the last day of in- 
terval (72). It might be said that in these less robust subjects, there 
was defective reaction after the first febrile attack, combined with per- 
sistent irritability of the circulation. 

Duration. — The first interval was computed to last from the day 
after the crisis to the day before the relapse, both inclusive ; and it was 



PYREXIA — FIRST RELAPSF. 1 45 

found in 190 continuous instances to have a mean duration of 7-4 days, 
an average duration of 8"i, and an extreme range of 3 to 12 days. The 
instances of extremest range were very few, especially those of the 
shorter period. It is remarkable how nearly alike is the duration of the 
invading attack, and that of the fifst apyretic intervals — viz. as 7 "5 to 7 "4 
days : still the two events are probably not connected, for a relapse is 
by no means invariable, and analogy points to the association of each 
non febrile stage with the succeeding pyrexial attack. Apparently there 
is no fixed relation between the duration of interval, and that of pre- 
ceding or following febrile event ; or between it and the intensity of 
fever in these attacks. Nor has experiment on the quadrumana eluci- 
dated the conditions of varying incubation-period and febrile manifes- 
tation: probably they are not simple, but complex. The close of this 
first interval is attended with a visible blood infection and both t. and p. 
may indicate some concurrent perturbation ; as a rule, however, there 
is little that is certain recorded, and more elaborate research is still 
required ; my experiments on the temperature observed at even 3-hour 
intervals not being quite conclusive. 

Second Febrile seizure ; first Recurrence or Relapse. — Usually this is 
a prominent feature in the patient's illness, being almost tantamount to 
a reproduction of the invasion seizure terminated a week before : less 
often it is comparatively insignificant, and between these two extremes 
there occurs almost every variety of form, intensity and duration of 
pyrexia. Even when brief, the fever commonly presents marked diurnal 
exacerbations ; and this paroxysmal character tends to prevail in re- 
lapses of 3-4 days duration ; in pyrexia of 5-6 days it is still apparent 
at first, the subsequent tendency being towards more continuous type. 

In consequence of so great liability to variation, it becomes difficult 
to convey briefly an adequate conception of the relapse : 30 cases have 
been selected for analysis, all in survivors and free from complication, 
of 4-7 days' duration, and dating throughout the epidemic. The whole 
group will first be considered ; then each series of most to fewest days*^ 
length ; a few examples of short relapses being added to complete the 
description : remarks are based upon bi-daily records. 

Initiation. — Some hourly observations made at the beginning of the 
relapse shown in Chart 2, Plate IV., prove that when chills occur at 
onset of fever, they do not supervene until the temperature has already 
risen : — 7 a.m. — t. 100° -4, p. 86, no chills or headache, bilious vomiting 
with uneasiness over site of gall bladder : 8 — t. 100° '4, p. 90, no chills 
or other sign of uneasiness : 9 — t. 101°, p. 100, no chills, some aching in 
loins, no splenic uneasiness: 10 — t. 102°, p. 108, no chills : 11 — 1. 102°, 
p. no, slight chilliness, no headache, hepatic uneasiness : 12 noon — 
t. io3°"4, p. 112, still sense of chills, no headache : i p.m. — t. io3''-6, 
p. 126, still sense of chills, no headache : 4 — t. io4°'2, p. 150, chills 
ceased. 



146 



SPIRILLUM FEVER. 



TABLE X. — Mean T. and P. of First Relapse : T. in continuous line, 

P. LINE DOTTED. 




Temperature. — The general mean temperature was m. 102° "9, e. 
104° + , with daily range of i°"i6,or5° to 1° F. above that of the invasion: 
range greatest on second day : general course indicative of a slight 
ascent from first to last, initiation and fall abrupt The line of mean t. 
here shown is more or less closely conformed to by some examples of 
continued recurrent pyrexia ; but it is of artificial construction, and the 
fever of spirillar relapse is not found to be generally continued in type, 
when charts are viewed in detail ; for these individually display a highly 
diverse contour of mingled form. 

The extreme temperatures were contemporary with the mean, being 
min. 99° '3 on 2nd morn., and max. 106° on last even, at acme : daily 
range greatest on 2-4 days, and least on first and last day ; so that it is 
not so much at beginning and ending of the first relapse as during its 
early course, especially on second day, that great variations of t. were 
noted. 

The daily course of the fever after initiation may be summarily de- 
scribed as follows : the second day is marked by a morning fall usually 
very decided, the evening rise which follows being ecjually pronounced ; 
and these events may prove the minimum and maximum of the entire 
attack. The decline may be deferred until the third morning, and may 



PYREXIA — FIRST RELAPSE. I47 

be so considerable as to amount to an intermission ; the succeeding rise 
is the commencement of a second paroxysm and is almost universal. 

Third day : similar morning remissions and evening exacerbations 
occur, but both less pronounced. When the initial paroxysm has been 
prolonged over the second day, the marked fall and rise of that day 
are transferred to the third ; and in cases where the attack ends on the 
fourth day, the final, and it may be the highest, rise occurs on this 
evening. 

Fourth day : the majority of instances display a rise and fall more 
limited and approximated, so that the tendency is for the pyrexia to 
increase and become more equable. Modifications result thus — in the 
prolonged and, as it were, slower morning paroxysms of long attacks, the 
m. t. may come to represent he second rise usually happening on a 
previous evening, and as it then exceeds the t. of the same e. there 
ensues the seeming anomaly of a higher morning t. : this event, though 
rare, shows the independence of the spirillar paroxysms. In case of an 
attack terminating next day, the evening t. may rise beyond the mean 
on this day. 

Fifth day : instances are now fewer : m. fall decided, ranging about 
103°; evening rise considerable (over 104°) in the cases when the attack is 
to terminate next day ; more moderate in the slower rises of prolonged 
attacks, or as the low summit of an interrupted and deferred later fall. 

Sixth day : temperature either m. or e. forming the acme of a final 
rise (usually not considerable) or the main fall may be in progress this 
day : range 103°- 104° or lower. 

Seventh day : may display an interruption in the fall of an attack 
prolonged until now, or a superadded and semi-detached paroxysm 
similar to a first in the series composing the attack. 

Contours of first relapses. — Of loofully developed relapses the upper 
contour was ascending 22, convex 22, level 16, declining 16, cleft (bifid 
or trifid, with parting sometimes equal to an intermission) in about 14, 
a wavy contour or slight decline 6, and the remainder a single upheaval, 
as it were, of temperature. The lower or minimum contour-line was 
less regular ; in prolonged seizures the remissions tending to shorten at 
last, and in the briefer to become more pronounced. 

Form of fever. — No absolute uniformity was observed : thus, analysis 
of 69 representative cases gave the following proportions — continued 
form 26 p. c. ; the remittent 70 p. c, and intermittent (excluding single 
paroxysms) 4 p. c. : predominance of the remittent type, as commonly 
estimated, is here indicated ; and the occasional aspect of high fever 
perfectly sustained for two or three days, at one level, might be illusive 
and due to insufficiency of bi-daily observations. The continued form 
was oftenest declining or level in its contour, seldom ascending or dip- 
ping midway ; it was commonest in long relapses, and most frequently 
seen towards height of the epidemic : the remittent form prevailed 
throughout and was well marked in brief relapses ; it not uncommonly 
showed an ascending contour, the descending and level course being 
next in frequency : the intermittent form offered no predominant 
contour. 

Construction of the longer relapses, first and subsequent. — There 
was often perceptible a division of the whole event, by deeper remis- 



148 SPIRILLUM FEVER. 

sions, into 2, 3 or 4 main parts (secondary constituents or specific 
paroxysms) more or less alike, and variously composed of i or more 
daily exacerbations (primary constituents or fundamental paroxysms) : 
and it seemed to me that all the febrile phenomena following spirillar 
infection, might be accurately as well as conveniently regarded as being 
constructed of i, 2 or more of such specific paroxysms. Such hypothesis 
also assists in comprehension of the disintegrating process noticeable in 
different degrees at successive relapses, and exceptionally at invasion. 

The pulse in first relapses. — The pulse concurs with the temperature 
in its general course, but is apt to rise more slowly, and finally not to 
attain a frequency proportionate to the higher temperature of the relapse : 
hence the mean p. rate is not so rapid in the second attack as in the 
first, although the t. is 1° greater. I also find that the circulation some- 
times continues to be excited subsequent to the acme and beginning of 
crisis ; after the fall is established, the pulse declines rather more than 
at the invasion crisis, yet not descending to its minimum until some 
time after the lowest t. has been reached, and febrile reaction has made 
some progress. 

Whilst the perturbations of temperature are greater in the relapse 
than in the invasion, the pulse in following these changes is found not 
always to accord with their direction ; and not seldom the morning p. 
Avas in excess of that of the same evening. This divergence was most 
frequent on the 3rd day of the relapse, but was also seen on the 2nd, 
5 th and 4th, the evening t. on all these days being in excess of the m. t. ; 
one-third of all cases showed this peculiarity on the 3rd day, one-sixth 
on the other days ; and the explanation seems to be found in previous 
febrile excitement at night followed by depression of temperature, but 
not with so prompt subsiding of the pulse. In the tv^o main varieties 
of relapse seen amongst Hindoo immigrants and Mussulman weavers, 
showing respectively a briefer, sharper and ascending course of the 
pyrexia and a lower, level and more prolonged course, the p. was found 
to correspond pretty closely ; thus, in the first series, it began low (77) 
and rose in frequency to the end(i 10), and in the second, beginning high 
(no) it remained so, being most rapid of all (124) in this low typed and 
prolonged form of pyrexia. Upon wide review, the variations of pulse 
were found to be at least equal to those of temperature ; and in- 
stances of non-concurrence were somewhat more frequent than during 
invasion. 

Initiation of the relapse. — Whilst both briefest and longest relapses 
have a tendency to begin in the morning, those under notice of mean 
duration commence, like the invasion-attack, oftenest in the afternoon, 
in the proportion f to f ; about 60 p. c. of all first relapses commenced 
during daytime. The morning rise in accordance with normal move- 
ments of temperature was sometimes clearly made out, but generally it 
had commenced at some hour not known during the previous night, 
when the body-heat was declining : the exact time being rarely indicated 
by chills. At the hour of 7 a.m. the mean t. was 102° or a little over, 
which is 1° lower than that of m. initiation of the invasion: subsequently 
the t. continued to rise throughout the day, and in the e. it was 104°. 
Some 3-hour readings made during one of these short recurrences, 
showed a distinct check in the day-rise, taking place before noon, and 



PYREXIA— FIRST RELAPSE. 1 49 

indicating the occasional influence of normal cycle in even one-day 
relapses. 

The initial evening rise (rather the commoner) began usually after 
noon when the normal t. was proceeding to its maximum, and it con- 
tinued to rise till beyond this point in a few instances specially observed 
or until 8 to ii p.m. As noted at 4 p.m. the mean t. of evening rise 
was about 103°, or about 1° above that of m. initiation ; but 1° less than 
the e. t. following, and also nearly 1° less than the evening initiation of the 
invasion-attack. As compared with onset of the invasion-attack there 
is here observed both lower range and greater variability. I have often 
known the relapse set in as suddenly and sharply as the invasion, but 
generally it is not so, at either morning or evening ; and the second 
seizure tends to begin in an interrupted or gradual manner, which has 
not been seen at first. 

Pulse at initiation. — The pulse is quicker or slower as the rise of t. 
is more or less marked ; but in every series of cases examined there was 
an evident initial slowness of the circulation, which in some instances 
extended over i or 2 days. 

Perturbatio m/zVa;. —Probably this phenomenon was somewhat more 
frequent in this relapse than at invasion ; its general character being the 
same. A clear instance was that already described in the woman's case 
No. IX., when at 3 p.m. the t. had quickly risen to io8°-6, p. 150; an hour 
afterwards the heat had declined to 104° "2, the pulse not having changed, 
being doubtless too rapid to allow of precise measurement by ordinary 
means. Vide also Case XVII. 

The crisis in First Relapses. — Was generally more pronounced than 
either at invasion or in late recurrences. In 85 p. c. of cases it was 
noted at morning visit, and so far corresponds in time with the normal 
dechne of animal heat : reaction was then usually prompt : in 15 p. c. 
of instances the fall happened mainly or wholly during the day, usually 
being complete by the following morning. 

Rate of decline of temperature. — This does not appear to be more 
uniform than at invasion ; e. g. being for the completed phenomenon in 
the woman's case above, No. IX., i2°"6 (including the critical perturba- 
tion) in 19 hours, temperature falling quickest at first and midway 
(about i°*5 per hour), very slowly at the last (i'' per hour); the event 
occurred at night. Once there was a decline of 9°'8 in 22 hours, being 
quickest at first {i°-6 per hour) and also at the end (8° per hour) ; this 
was a day fall : and a third instance showed a decline of 6° -8 in 11 
hours, rather quickest at first (1° per hour) ; subsidence during the day. 
In two very brief relapses, a night decline at rate of about 1° per hour 
and of moderate degree was noted, being as usual rather slower as the 
minimum was approached. Other quicker rates for short periods were 
recorded, one of the more striking being noted at the height of the 
epidemic ; patient a man of 18 ; t. at 5 p.m. io5°"8 ; half an hour later 
t. 99°, twelve hours later 96°; here the main decline of near 6° took 
place in the first half hour of crisis. 

Degree of critical fall. — The mean elevation of fully developed first 
relapses being about 1° greater than that of ordinary invasion, by nearly 
as much is the crisis more marked in them ; its actual degree depending 



150 SPIRILLUM FEVER. 

partly upon prtvious seventy of fever. Thus, in relapses of 4-7 days' dura- 
tion the mean min. t. was 96° '2, and in those of 2-3 days' duration about 
97°*5. The more prolonged critical decline was not necessarily the 
most pronounced, but rather the contrary : for crises quickly completed 
were those furnishing generally the lowest thermometer readings : excep- 
tions, howe t'er, were met with, and the most striking of my early series was 
one of e. fall prolonged till next m., when was read the low t. of 94° ; 
there was another instance of decline prolonged from one e. to the next 
e. after a marked seizure of 6 days' duration, when the thermometer 
reading was 95° "2. These phenomena are striking. 

Low critical t. usually attended either 'continued ' pyrexia or those re- 
lapses of over 4 day ,5' duration in which the number of distinct exacerba^ 
tions v.as fewer than the number of days occupied by the fever. Acute 
isolated paroxysms seldom had a deep fall, but prolonged exacerbations 
were often followed by a great descent : intermissions during a relapse 
did not imply a deeper fall at the end. 

The Pulse at crisis. — Decline in frequency of the heart's action whilst 
followmg the temperature was less pronounced and less regular : it was 
most considerable in the marked and abrupt crisis, yet in general striking 
and unusual perturbations of temperature were not immediately attended 
with such fluctuations of pulse as might be anticipated if the normal ratio 
of t. and p. were maintained during fever ; and in every instance at the end 
of crisis, did the pulse remain in excess of the temp, as measured by the 
mean normal proportion of 98° : 74. The amount of this excess varied 
according to idiosyncrasy of subject and degree, and probably rate of 
fall. When the body-heat began to be restored, the pulse still continued 
languid, and for a time even declined. In three ordinary cases the 
pulsations at acme were respectively 150, 132 and 120, with t. of 108° "6, 
io4°-8, 103° ; and at end of crisis 86 (t. 96°), 70 (t. 95°), and 88 
(t. 96°-2). 

Duration of First Relapse. — In a series of 167 cases seen between 
May 1877 and October 1878 the mean duration was 475 days, mean 
extremes 4 and 6-2 days ; actual extremes i and 7 days ; average dura- 
tion 4 "3 : hence at its first recurrence the spirillum fever though usually 
very distinct, and occasionally nearly as pronounced as the invasion, 
may yet be exceedingly brief At invasion-attacks of man there is no 
such wide variation ; yet almost as great were noted in the monkeys' 
first and sole attack. 

Having reviewed the fully-developed relapses as a whole, I now 
subjoin a brief description of each individual series included in the 
group. 

7 -day relapses : rare : Of 4 instances, i approaching the continuous 
type, 2 remitting, i intermitting : it is noteworthy these long events 
were never composed of a single upheaval of temperature, but by de- 
pressions on 2nd and 5th mornings (deferred sometimes till 3rd m. or 
5 th e.) their construction of 2-3 main paroxysms, of varied prominence, 
was more or less clearly indicated, max. t. high and sustained : onset 
prompt and fall either direct and moderate (m.) or prolonged and 
deep (e.) 

6-day relap.ses : 8 cases ; a compact group of high pyrexias, exhibit- 
ing 2, 3 or 4 main paroxysms, those on 2nd and 5th days being always 



PYREXIA — FIRST RELAPSE. . 15I 

indicated by corresponding m. depressions ; general course of fever 
ascending and remittent (6 times) or level or descending and rather 
continuous (2) : max. t. high : onset chiefly m. and prompt : fall marked 
and at m. : intermittency not seen in this group. 

5 -day relapses : 8 cases in a compact series of intermittent type, the 
contour once only being in part continuous : main paroxysms 2 (by 
dip on 3 m.) or seldom 3 (when another decline on 4th m.); general 
height of fever moderate ; contour level, with depression near mid- 
course : max t. 105°, min. t. 101°: m. onset 5, sometimes rather low : 
fall at m. and of mean degree. 

4-day relapses : 21 cases : fever lasting 3 days and crisis on the 
4th : never quite uniform throughout, but divided by deeper remissions 
on 2nd or oftener 3rd m. : a main depression on 2nd e. and similar 
anomalous movements now seen, probably being peculiar : i or 2 main 
paroxysms, the last culminating in the perturbaiio crifica, as seen in the 
case of a girl with acme at 108° and fall the same night to at most 97°; 
m. onset 8, e. onset 13 : general height of pyrexia not quite equal to 
that of longer attacks : fall prompt and decided. In this large group 
fever markedly remittent, with tendency to change ; this character 
being most apparent amongst Hindoo agriculturists, whilst amongst 
Mussulman weavers the tendency was to less remittent or even con- 
tinuous type. 

3-day relapses : 10 cases, with fever estimated to last 32-44 hours : 
t. range 101° -5 or larger than in longer recurrences ; fall usually mode- 
rate : onset e. 6, m. 4 : composition of 2 distinct paroxysms, varying in 
height, continuous or sustained (2), remittent 5, intermittent 3: the e. t. 
always predominated. Bi-daily observations are insufficient to determine 
the actual duration of the febrile paroxysms, and a correct estimate of 
these brief relapses, which offer a natural analysis (as it were) of the 
spirillar pyrexia, is still a desideratum. 

2 -day relapses : 18 cases. As fever lasts but part of one day, sub- 
siding on the next, these events appear in common charts as single, 
isolated paroxysms resembling other brief febrile attacks of various 
characters. Onset— noted at e. 11 (previous m. t. 98°-99°) ; noted at m. 
7, with t. 99°-io3°"6 and the lower rising during the day (previous e. t. 
about the mean) ; time of advent of fever prior to 7 a.m. not known, but 
it certainly may occur in the night and thus prolong these brief relapses 
to the 3-day series : estimated duration of pyrexia 6-48 hours during 
these remarkable single, isolated paroxysms ; but when most prolonged, 
doubtless remissions occurred midway. Not very seldom the main 
paroxysm was preceded or followed by minor exacerbations, for a day or 
more : and two distinct events might occur separated by a day's apyretic 
interval, such occurrence being repeated also as second relapse. Temp. 
1 00° '8 to 106°, mean 103° "3 ; acme at e. almost always : critical fall, 
seldom marked but the t. has been known to descend to 97° after 
highest acme, and, as if to show how peculiar the fever, it was once 
noted at 94° after an acme only about the mean : possibly with more 
frequent observations such sub-normal fall might be generally detected, 
for in a later instance than any of the above, and examined at 3-hour 
intervals, a min. t. of 96° detected at 5 a.m. would have been overlooked 



152 



SPIRILLUM FEVER. 



in the ordinary chart which gave 2 hours later 97° '2 : this point is of 
interest in a diagnostic sense. 

Date. — Both fully- developed first relapses and these highly abbre- 
viated forms may be said to commence after an ordinary apyretic 
interval of similar mean and extreme duration : for the present series 
these being 8'3 days and 3'i2 days respectively; the average 6-10. No 
instance occurred of an isolated spirillar paroxysm after invasion, outside 
these limits ; and at the earlier of these dates but few were seen, in small 
children and women. The patients generally were of ordinary type and 
condition ; nothing being noted to indicate the reason of their partially 
suppressed relapse. 

The pulse rose with the temperature, and in general proportionately: 
sometimes it was slower than might have been anticipated, or lagged 
behind. In the briefer attacks the mean p. at m. prior to e. rise was 
83 ; and 75 at e. prior to subsequent rise (the difference being notable): 
at acme its mean was 105 with mean t. of 103° '2 ; and at fall 83 with 
t. 98°, commonly sinking a little lower afterwards, but not in a definite 
manner: sometimes the p. was slow throughout : the max. was 120 with 
a t. of 1 06° "6. In attacks lasting two full days or a little over, the p. 
attained 112 with t. io4°7 at acme ; and declined to 81 with t. 96°'6 at 
fall ; afterwards becoming still slower in some cases ; at the min. t. of 
94°, it was 80 : it may continue rapid, or still rise, after the acme of 
temperature. 

Second Apyretic Interval. — The second interval lasts longer than the 
first and is, like it, a quasi-normal state ; the general level of body-heat 
is slightly lower, but the course is aUke : rebounds and complications 
are less frequent, the tendency to convalescence being more evident. 
The pulse is, on the whole, slightly quicker than it was during the first 
interval ; it follows a similar course. Fourteen typical examples have 
been analysed, uncomplicated and taken at early and late periods of the 
epidemic : the majority correspond fairly well, but the four cases of 
weavers show more variations of p. and t. than wxre found in the 
robuster agricultural immigrants. 

The following tables and charts were those of a series of cases seen 
at the J. J. Hospital in 1877. 



TABLE XI. — Mp:an T. and P. in Srcond Intkrval. 




M. 96 7 97-3 97-6 977 977 97 '9 97 '« 977 97'^ 97'6 98'4 
K. 97-3 98- 97-9 93-1 98-3 98-2 98-2 983 98- 97-8 



PYREXIA — SECOND RELAPSE. 153 

Individual charts show many variations : the mean morning t. Was 
highest on 6 day ; mean e. t. were always higher than m. t., the maximum 
being on 5 day : the m. pulse was higher than the e. p. at firsi ; the p. 
declined often considerably at the end. The cases collectively show a 
distinct perturbation of T. and (more) of P. about the 6th day, which 
consisted of a rise and fall : in another series the p. alone indicated 
this disturbance, once- falling to 64 on the sixth m. and rising to 92 on 
the following m. : general symptoms may be quite absent, and the 
blood-parasite has not yet been found on these occasions. 

The above chart refers to cases in which a second relapse occurred : 
regarding the corresponding period not followed by relapse, I found 
similar indications of systemic disturbance (best manifested by the pulse 
rising and faUing) on the 6th, 8th and loth days : these perturbations 
are, however, most marked in the relapsing set, beginning a day or two 
before the attack comes on, when the blood-parasite may be present. 
There is a third series before me in which, whilst the general course of 
t. was nearly level, more marked variations of both t. and p. were pre- 
sent ; the t. being most depressed and p. most variable, when a second 
relapse took place : this set belonged to the weavers who in general dis- 
played a lower type of fever, and more minor complications. 

Reckoning from the first rise after crisis, the initial t. (96°'5) is 
rather lower than at the beginning of the first interval : the pulse is 
usually about 80, but varies considerably : at the end whilst the t. 
becomes almost normal, it is apt to decline considerably. 

The duration of the second interval was 9 days in four instances, 
10 days in three, and 11 days in two : another series showed a range of 
6 to 14 days, the tendency being towards the longer periods. 

SecoJtd Relapses. — These hold the same relationship to first relapses 
as those to invasion seizure ; and the pyrexia is found to become still 
briefer, less sustained and less pronounced : it might usually be termed 
mild, and there were gradations of decline to mere febrile perturbation, 
hardly to be perceived. Such slight indications of the relapse were 
probably common, but might occur at night and hence appear in the 
chart as a depression following fever. 

Form. — Amongst 27 examples continued pyrexia none, remitting 7, 
intermitting 13, isolated paroxysms 7 : contour of remittents mostly 
level or descending, of intermittents more varied ; the longer relapses 
sometimes showed an increscant course of their component paroxysms. 
The tendency to disintegration and dissociation of pyrexial elements, 
or even their partial suppression in mid course, being combined with 
mildness and brevity, it follows that these later relapses are, in all re- 
spects, less severe than the earlier. 

Temperature. — The max. t. for all forms was 105°, seen only four 
times: for both remittent and intermitting the mean max. was io3°'3 ; 
for single paroxysms 102° '5, these data pointing to a tolerably well- 
defined limitation. In the absence of continuous fever, a distinct per- 
turbatio critica was not seen ; but the final paroxysm of a remitting 
attack was sometimes so predominant, as to suggest that here might be 
perceived the real paroxysmal character and relation of such final exacer- 
bation. 



154 SPIRILLUM FEVER. 

Minimal t. — A morning t. below the normal at initiation of relapse 
was common, as resulting from the generally depressed state of the pre- 
ceding apyretic interval : remissions of pyrexia were usually well marked, 
and the not infrequent intermissions at 2nd morning, or even 3rd, may 
descend to 97° : such low mid-temperatures were extremely rare during 
the two earlier febrile events, here they were noted in at least one-fourth 
of comparable instances. 

When the low level was prolonged, the number of febrile paroxysms 
became reduced to fewer than that of days : in similar instances the m. 
t. was occasionally higher than e. t., contrary to the rule otherwise in- 
variable here. 

The crisis of these modified relapses was seldom marked ; but its 
occurrence was sometimes indicated, after even isolated paroxysms, by 
a depression below the normal not seen in other kinds of brief fever. 
The rate of febrile subsidence was either abrupt or more gradual, when 
the minimum t. was not attained until the and 01 3rd m. after main 
decline : this feature also appears peculiar. 

Range.— The extreme daily range noted amounted to 7°, but the 
mean was considerably less than thisj owing to the very moderate height 
of the usual paroxysms ; still, however, being in excess of that in earlier 
relapses attended with so much less tendency to intermit. 

Duration. — In 7 instances the pyrexia lasted a part or the whole of 
I day, the fall being noted either next m. or not until e. (whence a vary- 
ing duration of these briefest forms) ; in 6 the relapse was of 3 days' 
standing (2 remittent and 4 intermittent) ; in 8 of 4 days' (3 remittent 
and 5 intermittent) ; in 3 of 5 days' duration (2 intermitting); in i of 6 
days', and in 2 of 7 days' duration, these last examples being intermit- 
tent in character, exceptionally long and possibly complicated. This 
enumeration is instructive as pointing, by a sort of natural analysis, to 
the ultimate construction of late specific febrile events ; and also indi- 
cating how near the fundamental elements approach to those of malarious 
fever, or possibly of all other acute febrile infections. 

The Pulse in second relapses. — The pulse follows the temperature, 
though not very promptly ; hence at the first rise, it often seems 
comparatively slow {e.g. 100 : 104° -4) its maximum not being noted 
until several hours after the indicated maxinmm t. (no : io3°'4 in an 
example just quoted) : for the same reason the p. is apt to be quickest 
at the close of a prolonged and uninterrupted third attack ; there were 
instances also where the pulse did not rise at an initial paroxysm, with a 
t of 101° or 102° ; though it sank with the mid-depression, and rose 
with later exacerbations. So far as seen, its frequency was never exces- 
sive, e.g. 104 : 103°, or no : 104° ; yet there are here, as well as at 
other times, individual exceptions of a rapid pulse throughout, and also 
for a brief interval after an attack ; in children, too, the p. was always 
quick, even during the apyretic state. An interesting case is included 
in the present series, which serves to show that the p. follows the t. and 
not alone spirillar inspection of the blood ; and there are others showing 
a minimum pulse in the mid-depression of an interrupted specific relapse, 
so that It again seems as if these late events were composed of distinctly 
•^separate recurrences. With a gradual rise of t. culminating in, or under- 
lying, or following an acute paroxysm, the p. also rises above the mean ; 



PYREXIA— THIRD RELAPSE. I 55 

and in perfectly intermitting paroxysms of specific character, it has been 
found to sharply vary in rapidity. 

Owing to the extremely diverse forms assumed by second relapses, 
I have found it impracticable to draw up a useful table and chart of mean 
t. and p. 

Third Apyretic hitei-val. — With the rarity of 3rd relapses, this corre- 
sponding incubative period becomes equally uncommon in hospital prac- 
tice ; and in an earlier series of 150 cases of relapsing fever, only 6 
instances were met with, the 3 better verified being here quoted. In 2 
its duration was 14 and 17 days, or 5 and 4 days longer than the second 
interval, and 7 and 10 days respectively longer than the first, and in the 
3rd case, its duration was also 17 days, the previous apyretic intervals 
being of average length but interrupted by intercalated paroxysms. 
From these data (which are confirmed by others) it appears that whilst 
the successive febrile events diminish in duration, their incubation-stages 
progressively increase, the means here being 8, 12 and 16 days of first, 
second and third intervals respectively. 

This prolonged stage may differ but little from the normal ; once 
there were complications, in two cases the t. was slightly depressed at 
first : a brief decline on 9th day (t. 97°'2 and p. 76) with some headache 
and pains in the joints was noted in one of these two ; and in the other, 
similar general symptoms on loth day without evident alteration of t., 
yet wath a p. then at maximum (84). Trivial as they seem, such indica- 
tions of periodic perturbation are comparable with the similar and more 
marked disturbances seen during the preceding intervals, being also 
probably of specific nature. The crossing of t. and p. shortly after crisis 
is only occasionally seen in these late charts. 

When no recurrence ensues, the third post-febrile period may 
speedily assume the normal form ; sometimes, however, there were minor 
perturbations of t. or p. with or without slight general symptoms, 
about the loth day ; e.g. in one instance on 12th and 13th days with no 
recorded deviation of M.. and E. temp., the m. pulse promptly declined 
to 48 per minute, and then rose to its previous level of about 68 ; head- 
ache, giddiness, debility, pains in the joints, were complained and the 
spleen was enlarged : a minuter scrutiny was not made. 

Third Relapses. — These are milder, and at least equally varied ; 
being either distinct events, not to be overlooked, or comparatively 
trivial, or so obscure as to become hardly distinguishable : 6 examples 
are here analysed, the charts being of ordinary kind. 

Temperature. — The pyrexia lasted i day once, 2 days twice, 3 days 
twice and 4 days once ; its onset was at M. 3 times and as often at E. ; 
its termination usually noted in the morning : the prolongation beyond 
two days was attended with gradual decline, uniform or remitting. 

The form of fever was that of isolated paroxysms (3 times) or re- 
mittent ; the tendency always being to early acumination, and hence the 
general form paroxysmal, rising abruptly and remitting by degrees. 

The intensity of pyrexia was moderate, mean max. t. 103°, extremes 
1 04° -8 and 99° '8 : in absence of marked crisis the mean min. t. was only 
98°-2, absolutely lowest 97°'4, which contrasts greatly with earlier crisis ; 
here, again, a decided sinking of the t. is consistent with previous very 



156 SPIRILLUM FEVER. 

moderate rise. The single, isolated paroxysm of one day attained 
1 04° '2 ; of two-day seizures the max. was 103° -2 ; of three-day 103° -6, 
and four-day events io4°"8 ; hence no rule was apparent here : thet. at 
morning, especially at first, tended to exceed that at e. : the whole daily 
range was from 1° to 5°, and neither first rise nor end usually reached 
the full range. 

The Pulse in third relapses. — Whilst following generally the tem- 
perature, its course is often more variable and not concordant at morn- 
ing or evening ; its comparative exaltation is less (the velocity never 
being excessive) and its range more limited : thus with t. of 103° '2 the 
p. was 96, and with io3°'8 it was 102 (isolated paroxysm) : when the re- 
lapse was rather prolonged, the p. did not rise promptly and might not 
attain its maximum until after the t. has begun to decline ; it has been 
seen to remain low whilst the t. was rising. At the end, it may not de- 
cline below the normal ; or not until two or three days after the slight 
crisis. 

Fourth Relapse. — For the comparative discussion of the latest events 
in more prolonged spirillum fever, no adequate materials were procur- 
able from hospital practice ; since patients showing a tendency to fre- 
quent repetitions of the fever, could not by persuasion be detained in 
the wards long enough to allow of demonstrated absolute convalescence. 
There is but one instance of a Hindoo lad who after a well-pronounced 
first relapse, had three other minor attacks at increasing intervals of 5, 
7 and 1 1 days, but he left before the end of the series was determined. 
Here the fourth interval of 11 days displayed a level temperature 1° 
below the normal ; the pulse was also uniform about mean, except at 
first when it was depressed, and again at the close when it sank on the 
second morning before onset of fourth relapse. This event was repre- 
sented by a distinct, isolated paroxysm extending over two days : acme 
on the second m. with t. 104° and p. 120 : both commencement and 
decline were abrupt : at the m. fall the t. was 97° '4, whence it slowly rose 
to 98° '2 ; the p. being 76 and gradually declining to 60 on the third m,, 
after which it rose to a level still below the previous average : the suc- 
ceeding five days of his stay displayed a common level nearer the noruial 
than in the last preceding interval. 

Comparison of Ternperature jtwvements and Fjilse, during the Fever of 
Man. — The generally uniform concordance of temp, and pulse obser- 
vable in health was invariably indicated during the febrile state, a sus- 
pension or reversal of such concordance being unknown ; personal 
variations noticed in health were also repeated in disease : these state- 
ments are of clinical importance. Besides the many M. and E. pulse 
data collected from the beginning of my enquiries (for I endeavoured 
always to associate clinically these elements of the pyrexial condition) 
which are analysed below, there are some tri-hourly memoranda (also 
detailed here) which may be summed up as follows. 

Brief isolated paroxysm. — R, 50, whilst the body-heat rose 6°, the pulse 
quickened only 26, but six hours after the febrile acme of attack it be- 
came a little more rapid, although the temperature had declined 5° "2, 
hence in even a short paroxysm of 12 hours' duration, the pulse attained 



PYREXIA— COMPARISONS OF TEMPERATURE. I 57 

its maximum less promptly than the temp, it also declines more slowly : 
see the Chart ga Plate IV. 

During a longer specific paroxysm (M., 35) the pulse remitted much 
more strikingly than the temp., and after the common acme it declined 
more slowly, not having subsided to within 10 beats of the normal at the 
end of fall, when the temp, had sunk 8°, or to 2° -5 below par. 

In the case of the lad S. J. {vide Chart 2), the pulse quickly rose to 
its maximum, its subsequent course being however sustained ; and at the 
crisis it declined more slowly than the temp. In detail, it was seen to 
remit at the beginning when the temp, did not, it also declined at high 
levels when the temp, did not, yet it did not subside so quickly at the 
crisis. 

In the case of the woman M. {vide Chart 3), whilst there was a dis- 
tinct concurrence of pulse and temp, throughout the relapse, yet their 
independence was shown by the varying change of level shown by the 
pulse, and hours are noted when the pulse lagged or fell not in accord 
with movements of body-heat, the reverse conditions not being so evi- 
dent : if confidence be placed in these last observations, the divergencies 
I now note become of much interest, and certainly claim attention. 
Other more apparent features of the spirillar pyrexia are shown in the 
Chart, and are detailed below. 

I have not access to corresponding data with regard to other ' fevers,' 
but from a few observations made in malarious attacks, should not sup- 
pose these comparative movements of temp, and pulse to be peculiar to 
the spirillar pyrexia. 

Comparison of Febrile movements with JVor??ial daily course in 
Man. — Four examples of spirillar pyrexia lasting 12 hours ('), 30 hours (^), 
3-^ days (^) and 4 days if), showed that brief fever may culminate at 
10 P.M. (') and may remit in its progress upwards if) ; that the beginning 
of a longer attack may happen during the night in anticipation (as it were) 
of normal rise, the high level be contemporary with or oftener prolonged 
after hours of normal elevation, the ensuing decline (so-called •' remission ') 
being also delayed till 7 or 10 a.m. ; at close of attack, as at initiation, 
variety is more probable, as an added exacerbation or remission not re- 
presented in the mean normal chart : the critical fall may occur between 
I and 10 A.M. (^) ; and lastly the longer attack displayed a similar p.m. 
initial rise, remissions within normal range and exacerbations so prolonged 
as to occupy the midnight hours usually attended with decline of body- 
heat ; this last fact clearly indicating the operation of superadded pyro- 
genetic agency. From these data I infer that there exists a decided 
tendency of the specific pyrexia to follow the normal daily cycle, subject 
only to question of degree. 

I note, too, first, that a reversal of the entire daily normal movements 
of body-heat was never witnessed ; next, that some, at least, of these 
mid-febrile movements might be termed exaggerations of normal varia- 
tions : and lastly, that the prolonged rise and decline of febrile tempera- 
ture might be regarded as due to suppression of paroxysms, nearly or 
quite complete. 

Comparison of Febrile movements in the Hiwtan afid Qtiadrumanous 
subject. — In comparisons of the kind here attempted, it is not required to 



158 SPIRILLUM FEVER. 

include minute perturbations, nor is it the degree so much as the course 
of temperature which is important ; a similarity being established when 
the general course of body-heat is alike. Although its normal standard 
is about 3° F. higher than that of Natives, yet such similarity of the 
monkey's temperature to man's is evident enough ; and hence the in- 
ference of febrile movements also being possibly similar. 

The common mean daily cycle in health may be estimated as follows 
— a low level from 11 p.m. to 5 a.m. (minimum soon after midnight); 
a rising of body-heat from 5 a.m. to 11 a.m. ; a high level 11 a.m. to 
5 P.M. (maximum near the close) ; and a final period of decline from 
5 P.M. to II P.M. The febrile movements in Man being already in- 
dicated, I found those in the smaller animal to be thus : — in 11 instances 
of specific pyrexia lasting part of a day, the beginning fell within limits 
of normal rise 10 times, once being rather earlier ; the acme of attack 
came within high level limits 8 times, being earlier 2 and later i ; the 
critical fall concurred with limits of normal decline as often, being twice 
somewhat deferred. In 7 more pronounced attacks lasting from i|- to 
4 days, and altogether including 21 distinct day paroxysms, I found 18 
of these paroxysms happening within normal elevation limits and 3 coming 
on later ; whence appears the strong tendency of spirillum fever to concur 
with the normal rise, exacerbating also at rise-periods or soon afterwards ; 
the acme of fever was seen 19 times during normal, high level Hmits, 
tending to be deferred till night and the latest at 10 p.m. : ' remissions ' 
or partial decline of temperature were noted at both normal decline and 
low level periods, and the critical fall rather oftenest occurred within 
low level limits. Apparent exceptions to rule here being due to the febrile 
state anticipating or extending beyond normal high level periods, it may 
be said that the course of fever was essentially the same as in man. 

Lastly, having reduced the comparative charts to the common clinical 
form and contrasted them with ordinary charts of contemporary human 
patients, I find as follows : — in Man of 22 febrile paroxysms seen at close 
of invasion-attack, 19 were entered as E. the 3 at M. including strictly 
abnormal critical perturbations : the ' fall ' was entered at M. except when 
taking place by lysis or prolonged more than usual. Of 41 paroxysms 
seen in the relapse 37 were entered at E. : of 12 initiations 9 were noted 
at E. and of 1 2 critical ' falls ' 7 were noted at M. the remainder being 
prolonged later. So in the comparative series, 7 of 9 brief attacks came 
under E. ; and of the longer attacks all 7 beginning at E., 15 of 16 mid- 
paroxysms were also entered at E., and 6 of 7 critical falls at M. 

The force of these statements rests on the fact that when the detailed 
normal charts of either Man or Monkey are condensed into the ordinary 
M. and E. charts of clinical medicine, there is shown simply an E. rise 
with M. decline : and since in pyrexial charts most rises or exacerbations 
were marked at E. and most remissions or crises at M., the correspond- 
ence of main normal and abnormal temperature movements becomes 
apparent. Such corre? pondence may not, however, apply to details ; for, 
so far as known, subsidiary perturbations are more marked and probably 
more numerous during spirillum fever than in health. 

Non-spirillar fever. — Respecting later relapses and other more inci- 
dental sequelar paroxysms, not being in possession of fully detailed data 
I can state only that in ordinary charts the temperature movements were 



VARIATIONS OF SPIRILLAR FEVER. I 59 

similar to the verified specific. Also with regard to rebounds or secondary 
fever, the E. exacerbations and M. remissions being common where pyrexia 
is maintained (the beginning and ending almost necessarily offering 
variations), it may be inferred that these features belong to several forms 
of ' fever ' : and such inference would be supported by the charts of my 
experiments on monkeys with salivary poisons, by those of pytemia, hectic 
and certain other forms of symptomatic fever, the instance of enteric 
being good for essential pyrexias. 

No peculiarity therefore can be claimed here for spirillum fever. 

Variations of Spirillar Fever. — Commonly the results of infection 
are so complex and prolonged, that a priori it might be supposed they 
would be liable to much variation ; and as matter of fact, they are never 
identical in my two cases More remarkable, however, is the natural 
tendency of successive febrile attacks to diminish in severity, and to 
become deferred in occurrence. And, briefly, the variations I am about 
to consider are essentially modificntions of this progressive decadence, 
as it affects either febrile stages or apyretic intervals. Changes in the 
'type ' of fever are not here included {vide Chapter VIII. of this sec- 
tion) ; and fever with complications is not now referred to. 

Variatiofis of Pyrexia. — Regarding the several stages of Invasion 
and Relapse, since the spirillar pyrexia is never absolutely continuous 
and never exceeds the limits already named of duration and intensity, 
variations here stand for unusual phases of checked development, as 
represented by shortening, sinking or disintegration of pyrexia ; or non- 
specific paroxysms may be mingled, and the briefer relapses apparently 
lose part of their specific character. Regarding the sequence of phe- 
nomena, whilst the natural tendency is to subsidence, as extremely rare 
exceptions this order may be reversed and become increscant ; or it 
may be interrupted by intercalation of an additional paroxysm, or by 
apparent reduplication of a relapse ; and, on the other hand, a relapse 
may be deferred. An individual may undergo repeated infection ; and, 
for convenience, instances are appended to this Chapter. Truly errant 
forms of spirillum fever were not numerous, and such as are known 
being connected by intermediate gradations with the common type, it 
would be diflScult accurately to estimate their relative frequency. 

Some possible modifying influences were the following : — 

Age. — Infants at the breast displayed relapsing attacks with high pyrexia, 
or died during the invasion as do adults ; some children under puberty 
showed quite typical relapses with high fever {e.g. io8° at acme of ist 
recurrence by a girl of lo), or more irregular intermitting pyrexias : the 
critical fall of temperature was seldom pronounced : single attacks seem 
to be rare. All cases belonged to affected families : girls were unusually 
frequent in the lists, a malarious taint and the presence of lumbrici 
w^ere common. In all young subjects the pulse was very frequent. Old 
age does not entail essential modification of specific pyrexia. 

Sex. — Amongst women aborting the spirillum fever was not ap- 
parently severer than usual, or complicated wath local disease or secon- 
dary fever, thus 3 of 6 cases actually witnessed were all relapsing, the 
invasion-attacks being moderately prominent and the recurrences (after 



l6o SPIRILLUM FEVER. 

abortion) brief or irregular : in three other instances known chiefly by 
the patient's testimony, no pecuhar features were observed. 

Typhus biliosiis. — The connection of this fever, of either abortive or 
relapsing form, with pronounced jaundice and the typhoid state did not 
necessarily lead to peculiar modifications of the course, duration or 
intensity of pyrexia. 

Malarious influences. — Its conjunction with malarious fever pro- 
bably did not entail essential change in the earlier or more pronounced 
specific attacks ; and with reference to later, mild relapses, there 
exists at present considerable difficulty in discriminating the real cha- 
racter of such pyrexia. 

Symptomatic fever. — May be so blended and continuous with the 
specific that an attack really composed of two distinct elements might, 
without aid of the microscope, be erroneously regarded as of uniform 
character throughout. This remark applies also to the complication 
with secondary fever. Variations of pyrexia witnessed in fatal cases 
may be considerable, without displaying any particular form. 

Varieties of Invasion. — Judging from actual observation, a prolonga- 
tion beyond 8 or 9 days must be excessively rare ; and I placed no 
dependence on the statement of patients naming 12, 14 or more days 
as the duration of their first illness ; nor, I may add, is it likely their 
assertions were correct that the fever then intermitted. There is, how- 
ever, analogical testimony showing that the primitive spirillar pyrexia 
may vary much in duration ; for in the Quadrumana, I found its range 
to be from 6 to 86 hours, these extremes far exceeding in relative pro- 
portion any yet noted in man. Amongst ordinary hospital patients the 
first attack was never seen throughout ; and the comparatively few indi- 
viduals seized in the w^ards furnished the instances quoted below. 

I. The sole attack may be mild though continuous, and not lasting 
more than 3 or 4 days. Notes of three such cases are before me, and 
I feel confident that but for special blood scrutiny made with the micro- 
scope, they would have escaped notice in the crowded wards. Such 
were possibly only samples of this fever strictly comparable to the 
mildest forms of typhus and enteric fever ; which pass unrecognised 
except, may be, under the vague term of 'simple continued fever.' 
Moreover, in the East, malarious pyrexia of many minor degrees being 
common, there arises even greater likelihood of confusion ; and though 
I have not, as yet, seen in man the highly abbreviated simple paroxysms 
following infection in the monkey, yet on this negative point much 
reserve is needful ; and personally I should not be surprised to learn 
that the sole febrile evidence of spirillar infection amongst men, may 
consist of brief pyrexia but little more pronounced than is shown below 
to obtain in some relapses. 

Case XXVIII. — S. A., 35, lascar fireman, admitted August 1877 for mild ague, 
dysentery and secondary syphilis, general condition fair; there were occasional rises 
of temp, never above 100'-' F. for the first week, when pains in the joints and ulcers 
on the chin came on, but he wa5 gradually improving when Ociober 10 he had a 
sharp ague-like paroxysm, e. t. I05°8, p. 126, which left with sweating the next 
day : I examined the fresh blood during fever and could not detect the spirillum. 
A small sore now appeared on the penis, and in 9 days (no fever meanwhile) the 
temp, again suddenly rose with chills e. t. 103'' -6, \i. 120, and it remained high for 



PYREXIA — VARIETIES OF INVASION. l6l 

part of 3 days, then abruptly declined to 97° "2, p. So ; promptly regaining and keeping 
at normal level for lo days, when he insisted on his discharge. On the second day 
offerer m. t. 103°, p. 120, I found the blood-plasma clouded, fibrillation close-set 
and thick, white cells, large granule-cells and free protoplasm present, red discs 
piled ; numerous, active and rather large spirilla Throughout hepatic or splenic 
implication not detected, no jaundice, but vomiting at the crisis, no distress : after 
fall, much weakness and general aching pains. There were other specific fever cases 
in the same medical ward at the time of his illness, and I regarded the case as one of 
mild infection in hospital, which also might have been overlooked. 

2. The attack is irregular in form, being remittent, intermittent, or 
even interrupted in its course, and as this happens with severe general 
symptoms, it is evident that non-continuous pyrexia does not always 
imply mild disease. Some of these temperature-charts are so little like 
those of ordinary first attacks, that it once more becomes apparent the 
affection could not be recognised from them alone. How often cases 
of this kind occurred amongst ordinary hospital admissions, I am unable 
to say ; those recognised were found only amongst patients seized in 
hospital with specific fever, there being 4 or 5 in the series of 30 in- 
stances : the example quoted below might have been overlooked, had 
I not been struck with the man's physiognomy. This case I regarded 
as one of infection in hospital, yet should point out that although 10 
days had lapsed before the man showed symptoms, yet it is just possible 
an apyretic interval might extend so long, and the attack seen have been 
only a relapse : this is matter of judgment. 

Case XXIX. — M., 30, famine-immigrant only 8 days in Bombay, was admitted 
with looseness of the bowels and pains in the large joinis ; the former of 2 months' 
duration, the latter of fifteen days ; no mention made of fever : t. on admission 99° "8, 
p. 84 : much debility, no swelling of the joints, chest and abdomen seemingly un- 
affected ; the above symptoms abated in the course of a fortnight, and it was noted 
he is improving. 16 days after admission paroxysmal fever of intermittent and inter- 
rupted progress suddenly came on, lasting six days, and without manifest crisis, being 
succeeded by two or three minor brief elevations of temperature, which were non- 
specific in character : discharged convalescent. For the Chart see Plate IV. No. 5. 

3. In children an isolated attack of spirillum fever may be so disguised 
as regards pyrexia, that without extraneous aid the affection would in India 
be referred to smart febricula, or aguish attacks of undefined character ; 
yet the blood-parasite may actually abound at the time. Amongst 
infants and children, however, the vagaries of febrile reaction generally 
are well known ; and perhaps the most prominent instances of irregular 
compound attacks of this fever which I have seen, happened in young 
persons : much care is therefore required for discrimination of specific 
pyrexia, and the microscope becomes indispensable here. The fever 
in the youngest seems either to kill rapidly, or to be but mild ; prolonged 
and marked illness not having appeared in such subjects. Pyrexia may 
be high. 

4. Fatal cases.^ — Variations of pyrexia are more numerous and con- 
siderable here than in the surviving, even when no complication is 
present ; the initiation of illness being irregular and pyrexia ill-sustained, 
and not accordant with other symptoms : the pulse, too, varies much, 
though usually frequent. Such instances diverging amongst themselves, 
useful comparison becomes impracticable : but I would specially men- 
tion Causes XIII. and XVI. as examples of specific fever preceded for 

M 



l62 SPIRILLUM FEVER. 

three or more days by daily paroxysms of uncertain character, death 
occurring very soon after pyrexia became continuous : both subjects 
were infected from a common source. Not all fatal cases are thus 
irregular, at either beginning or course : when complications supervene, 
derangements of temperature become frequent. See Charts 15 to 19 
Plate V. and 25 to 27, Plate VI. : examples at extreme ages are Nos. 16 
and 17, Plate V. Lastly, the proportion of variations at invasion is not 
so considerable as in relapses — perhaps not more than one-tenth of all 
cases showing them ; but much remains to be learnt respecting the lesser 
effects of primary spirillar infection, in man. 

Varieties of relapse. —The order of natural decadence as indicated 
in Table III. is seldom widely departed from : variations of this kind 
known to me, include instances of a progressively increscant tendency, 
duplication of a relapse, and the intercalation of an additional par- 
oxysm. 

Respecting individual relapses, the same table shows how greatly re- 
current attacks differ in their duration, and hereby in clinical prominence. 
No rule obtains, for after a well-defined invasion there may follow either 
a pronounced or insignificant second attack, and so after a well-marked 
first relapse the next recurrence seems indifferently either very distinct 
or, in a sense, imperceptible. The more unusual variations here corre- 
spond to degrees of clinical effacement, through abbreviation, depression, 
or disintegration of specific pyrexia. Every collection of Temperature 
Charts contained examples of this sort. 

I. Variations referable to reversed or interrupted orders of occur- 
rence. 

a. Instead of the recurrent events more or less quickly declining, the 
first, second, or even third may sometimes be seen to augment in 
severity. Not uncommonly, the first relapse is rather more pronounced 
than the invasion-attack ; and less often, it may be equally prolonged or 
even longer by a day or so ; afterwards a second recurrence being rare. 
Two out of 1 1 native students seized in hospital with relapsing fever 
showed a predominating second attack, and in both the invasion had 
terminated by lysis rather than critically : the same features were noted 
in an adult woman attacked in the wards ; and also in an adult Negro, 
whose illness more clearly than usual was traceable to contagion at home: 
amongst five other examples selected for analysis, I cannot now trace 
the way invasion subsided. In these cases there was also a tendency to 
^^bbreviation of the preceding attack, and the apyretic interval might or 
might not be shortened : in all the general symptoms were pronounced. 

Inevitably little could be learnt of the beginning of these increscant 
attacks, but from a few data acquired amongst the hospital contagion 
series, I was led to suppose that spirillum fever here either begins mildly 
with a few isolated paroxysms, or is preceded by similar paroxysms of 
character unknown : this is a topic meriting attention as future oppor- 
tunity may occur. A striking example of the increscant variety was the 
following : — 

Case XXX.— M., 30, famine-iiTimigrant, thin and feeble; on admission said to 
have had fever for 10 days, t. 98^-2, p. 80, resp. 22 ; depression, headache, pains, 
some hepatic and splenic implication : the man had a sloughing ulcer on the back of 
the r. foot. There were febrile paroxysms on the ilth, 13th and probably 14th days, 



PYREXIA— VARIETIES OF RELAPSE. 1 63 

and on the 15th the t. rose to 103°, p. no ; a few spirilla in the blood ; splenic en- 
largement had preceded : on the two following days, rather milder paroxysms, and 
Mr. S. A. did not find the spirillum. With the exception of an isolated exacer- 
bation on 24th day, the man now remained tolerably free from fever for 9 days, or 
till the 27th day of illness, when a pronounced relapse set in, fever high at acme 
106° "2, p. 140, form remittent, duration 3 days ; a few spirilla seen on each day ; 
critical fall on 4th and 5th days, min. t. 95°, p. 60, much depression : rallying was 
slow, but the ulcer improved, and at the end of an interval of 5 days the t. was 
normal. A final recurrence now began (37th day of illness), onset sudden, range 
high, max. t. as before 106° '2, form remittent, duration 5 days, spirillum in the 
blood; critical fall next day, min. t. 96° -4 : a brief rebound followed (with dy- 
sentery) and thenceforward the body-heat was at normal level for 35 days, when the 
man became an out-patient. The nature of the fever prior to his admission may 
have been malarious, or due to the ulcer, or spirillar : the first specific attack 
detected was short and intermittent, the second seen more pronouncd, and the third 
still more prominent : so that the usual order of events was revei-sed : visible blood- 
contamination seemed to increase with repetitions of the attacks. It did not seem 
that the remarkable augmentation of specific symptoms was due to infection re- 
plenished through the fresh contagion in hospital, and there are obvious objections to 
such a view : the co-presence of a sloughing ulcer appeared merely incidental. 

b. Duplication of the ist and 2nd Relapse.— The following instances 
were recorded during my absence from Bombay : notes preserved and 
reconsidered : — 

Case XXXa. — M., 20, weaver ; after the invasion-attack of 9 days, form inter- 
mittent and decline lytic, there was a brief apyretic interval of four days, and then a 
first relapse extending over 10 days, and cleft by a deep intermission of some hours' 
duration between 3rd and 4th days ; termination by moderate crisis ; no apparent 
complication to explain this renewal of fever. Then ensued a long apyretic interval 
of 19 days, level and uniform, when fever returned as a series of 7 intermitting par- 
oxysms, varying in intensity, and of nature undetermined microscopically. 

Case XXXI. — M., 17, hospital sweeper (brother also attacked) caught specific 
fever in the hospital ; the invasion-attack lasted 7 days, the first apyretic interval 6 
days, and the first relapse 6 days : then followed an apyretic interval of 3 days, a 
febrile attack (non-spirillar) of 2 days, and another fever-free interval of 5 days ; the 
sum of these minor periods being ten days, which might be regarded as representing 
one second apyretic interval which had been interrupted by an intercalary pai^oxysm 
(see below), or else as narrated, as two successive intervals separated by a relapse : 
the next recurrence therefore represented either a 2nd or 3rd relapse, it consisted of 
two moderately elevated febrile attacks respectively of 4 and 6 days' duration, which 
were separated by an intermission of 36 hours' duration ; according to the record this 
recurrence was specific throughout : then followed a fever-free period of 19 days and 
discharge of the patient convalescent. 

Both the above attacks were unusually severe : commonly, a like prolongation of 
high fever was found to be due to either complication or secondary pyrexia, as 
defined in this work ; but since there seems no valid reason vi'hy spirillar pyrexia 
might not be re-duplicated, these instances are now quoted as sucli a very rare 
variation of relapses. 

c. Intercalated Relapses. — Under this term are included febrile 
paroxystiis happening between ordinary attacks of spirillum fever and 
apparently distinct from them. Such paroxysms were not very rare : 
notes of the five last examples seen, show their liability to occur during 
the first apyretic interval, though they were also noted in course of the 
second : they last i or 2 days, are isolated and pronounced (range 102°- 
5°), and had no clear distinguishing marks from the many brief final 
relapses reckoned as ist, 2nd, or 3rd : they appeared about midway of 
this interval, with 2-4 non-febrile days preceding and following. Both 
young and middle-aged showed them, and, it so happened, onlj men ; 

M 2 



1 64 SPIRILLUM FEVER, 

all subjects in average condition, and occurrence not exclusively limited 
to the later epidemic period. The preceding invasion -attacks were not 
peculiar so far as perceived, nor were the ensuing ordinary relapses ; so 
that no means appear of predicting such intercalations : local complica- 
tions were seemingly absent. The detection of these phenomena needs 
care ; in 2 or 3 of the above 5 cases, the blood-spirillum was present, 
once the blood was not (I believe) examined, once I could not be sure 
of the blood appearances seen : thus, results of microscopic scrutiny re- 
sembled those obtained in the examination of other isolated, periodic 
paroxysms occupying the position of a relapse : when not seen the 
parasite may have been overlooked. Prognosis of the cases not more 
unfavourable than usual. Such intercalated paroxysms may be regarded 
either as additional or supplementary phenomena, or, on the other hand, 
as relics of a partially suppressed relapse : the question here appearing 
to be one of judgment as much as of facts. It happens that 3 of these 
cases belonged to families, other members of which were affected with 
spirillum fever not offering these forms : the following was one of 
them : — 

Case XXXII.— M., 35, Mussulman weaver, famine-immigrant from N. India, in 
Bombay 15 days and 8 days ill with fever (a not uncommon statement), was admitted 
with his son and other caste men in Jan. 1880 : pyrexia moderate, much prostration, 
deep jaundice, a copious eruption of pink spots and many spirilla in the blood. The 
ferturbatio critica quickly followed, and a slight critical fall with rebound attended 
by pharyngitis ; 4 days after the crisis there occurred a smart febrile attack consisting 
chiefly of a single paroxysm, t. 104'^ -6, p. 130, spirillum present : there came another 
fever-free interval of 4 days, and an ordinary 2nd Relapse lasting 3 days ; the suc- 
ceeding apyretic period of 12 days showed temperature at normal level. See Chart 
No. 10, Plate V. 

By means of such additional paroxysms the specific attacks within 
ordinary limits become multiplied, and the intervening apyretic intervals 
sub divided. It sometimes happens that without any other change, a 
relapse (usually the first) comes on prematurely 3, 4 or 5 days after the 
preceding crisis, and it may then be decidedly prolonged. Such vagaries 
in the manifestation of spirillar infection were certainly not commoner 
than variations of malarious fever : probably others of the kind will be- 
come known. 

2. Variations of Individual Relapses. — Fifth, fourth and most third 
relapses are commonly represented by one or two brief paroxysms, differ- 
ing only in prominence : less frequently such stand in place of second, 
and seldomer of first recurrences. An example is shown in Chart No. 8, 
Plate IV., of a short, isolated paroxysm appearing as first relapse : — 

Case XXXIII. — M., 30. Invasion of 7 days with pronounced crisis; first apyretic 
interval of 7 days, temp, nearly level at normal line, but pulse declining at end : 
fever at 9 P.M. preceded by chills lasting two hours, next m. t. ioi°'6, headache, 
pains in legs, the spleen enlarged, projecting an inch below the costal margin, not 
tender, no hepatic implication : pyrexia was reported to leave at I A.M. with sweats, 
some headache, pains and splenic fulness still persisted ; t. at normal level ; the 
spirillum was found before acme. 

Relapses of three or more days' duration, whether first or second, are 
sometimes so disintegrated as to present a series of separate par- 
oxysms. 

Case XXXIV.— M., 14. First apyretic interval 7 days, level; first relapse 6 days> 



PYREXIA — VARIETIES OF RELAPSE. I05 

much pronounced and trifid, being cleft by two intermissions; second apyretic interval 
9 days, low and level ; the second recurrence had the form of two isolated paroxysms, 
separated by a non-febrile period of 34 hours, the first being pronounced (t. 105°), 
the second reduced (t. 100" '5), crisis moderate : the spirillum seen throughout the 
three days, disappearing at crisis. The fever set in at i P.M. with chills lasting an 
hour, headache, thirst, spleen not enlarged, sweating at end of first paroxysm ; during 
the non-febrile intermission, the symptoms were slight although the blood was visibly 
contaminated ; the final paroxysm began at noon without chills and left with sweat- 
ing : convalescence prompt. See Chart No. 7, Plate IV. 

Case XXXV. — M., 28, after a deeply pronounced invasion-crisis, an apyretic 
interval of 10 days at normal level until the end, wtien the t. declined to 97°. The 
first relapse of 5 days' duration consisted of four paroxysms separated by three inter- 
missions, crisis decided and prolonged : addi'ional temp, readings and blood-speci- 
mens were taken before and during the entire attack : they show the pyrexia to have 
been distinctly paroxysmal as indicated in the ordinary chart, the paroxysms differing 
in duration and intensity : spirilla present throughout, even at deepest intermission 
(t. 96°'2), being few and not increasing with the pyrexial exacerbations. General 
symptoms slight, no chills, sweats with defervescences, early splenic enlargement and 
soon after tenderness, which persisted a day or two after fever left ; also some epi- 
gastric uneasiness, and weakness : no subsequent return of fever for 22 days See 
Chart No. 6, Plate IV. 

These instances demonstrate the existence of a variety of specific 
pyrexia, which so strongly resembles intermittent fever in some of its 
aspects, that without some practical knowledge of relapsing fever and 
the use of the microscope, its misinterpretation was certainly possible. 
The Quadrumana did not display this disintegrated variety of pyrexia 
with continuous blood-infection; but they showed 6 times in 16 as the 
sole result of inoculation, a single brief paroxysm of 6-12 hours' duration, 
which under ordinary observation would be no more prominent than the 
relapse in Case XXXIII. above, and might resemble the quasi-latent 
forms to be next described. 

Variation by subsidence of Pyrexia : latent and suppressed Re- 
lapses. — It seldom happened that during a distinct relapse the tempera- 
ture was uniformly depressed, without the attack being also abbreviated : 
but in some feeble subjects and fever of low type, this variety was seen. 

When a relapse ceases to be distinct and is represented only by a 
slight rise of temperature, with very little else to attract attention, the 
process of suppression may be said to have affected all its dimensions ; 
and the Chart record becomes more or less obscure, according to the 
degree of arrest of pyrexia. In extreme examples there is seen only one 
or two brief m. or e. perturbations, or an unusual depression, or finally 
none but pulse changes. 

Instances are numerous of third and later recurrences being thus in- 
dicated, but no opportunity occurred of thoroughly testing their true 
character. As regards second relapses, however, I acquired the details 
of a case in which the common chart shows only a brief e. rise of 99° '2, 
with a depression next m. of 95° ; some additional observations made, 
however, prove this record to be imperfect, for at 10 a.m. of the first day 
the temp, had risen to 104° '6 and at 9 p.m. it had declined to 95° 'a. 
Microscopic examination demonstrated the presence of many spirilla in 
the blood, which also showed its infective property when inoculated in 
a monkey. This datum therefore becomes conclusive : here the chief 
sign of relapse was a very low m. temp, following a very slight e. rise. 

Another instance of the quasi-latent variety, occurring as a first 
Relapse, is the following : — 



i66 SPIRILLUM FEVER. 

Case XXXVI. — F., 46, Teeble, admitted with several relatives ai d friends from 
one locality, at end of invasion-attack ; moderate critical fall on 7-8 day : a slight 
rebound (t. 100°, p. 84) two days later concurrent with some bronchitis, thenceforward 
very slightly raised but uniform body-heat for 8 days. On 19th dayof disease e. t. ioo°-2, 
p. 64 : next day, m. t. 98°-6, p. 74; e. t. 97°'», p- 64, and no further change for six 
days till discharge. Here the slight rise on e. of 19th day was the only visible indica- 
tion of relapse in the ordinary chart of temperature ; but it happened that minuter 
observations were taken, those of body-heat from four to eight times a day during 
16-20 day of disease and those of the blood twice daily during the same period. 
Thus it was learnt that at lo P.M. of last day the t. rose to i04°-6, declining again 
during the night ; and I also found visible blood-contamination on the 17th and iSth 
day (with no rise of t.) as well as on the 19th, but not next day when the pyrexia left 
for good : this combined te timony being conclusive evidence that a veritable relapse 
had taken place, when upon bare inspection of the usual chart the occurrence might 
be considered at best as doubtful. The clinical notes are as follows, those regarding 
the blood being stated in the special chapter :— i6th day (date of possible relapse) 
m. t. 98° -6, p. 64, skin dry, tongue florid moist, no thirst, headache, pains or cough, 
slept well, one stool, spleen barely felt and not tender ; e. t. 98° -8, p. 66, feels better, 
though weak : blood unchanged : lO P.M. t. 99° -4, p. 64. 17th day,— m. t. 98°, p. 60, 
skin dry, no advent of symptoms, no heaviness of the body, good appetite, spleen 
unchantred, e. t. 98°-4, p. 60, feels weak but no discomfort : 10 P.M. t. 99°"6, p. 64. 
Blood — no spirillum in the morning, a few seen in the e. blood. i8th day. — 4 A.M. 
t. 99°, p. 68, 6 a.m. t. 99° "2, p. 66, skm dry, no change whatever, but increase of 
appetite and more food asked for: spirillum present : e. t. 98° -6, p. 62, respiration 
quiet, tongue whitish, moist, no headache, giddiness, thirst or discomfort ; splenic 
dullne'^s 2 sq in. only, not projecting to costal margin, no tenderness ; no hepatic 
change ; abdomen relaxed ; she has a haggard look but perhaps not more so than 
yesterday, and protests she is well ; eats heartily : blood-spirillum present. 7 P.M. 
t. 99°, p. 66 : lo P.M. t. 99° -6, p. 66, no discomfort. 19th day. — I A.M. 99°"4. P- 64. 
no complaint : 4 A.M. t. 99° "4, P- 60, no complaint : 7 A.M. t. 99° "2, p. 62, skin 
dry, no headache, thirst or pains, slept, one stool : spleen barely to be felt, not 
tender: no detectible local or general change. 10 A.M. t. 98°-6, p. 60: blood- 
spirillum present : noon, t. 99°, p. 60 ; 2 p.m. t. 99°"4> P- 64 ; 4 P.M. loo°-2, p. 64, 
no headache or thirst, feels very weak, no chills, spleen felt but not at all tender or hard, 
no epigistric uneasiness, protests she has no ailment (spirillum present) : 7 P.M. 
t. 102° -2, p. 78, feels chilly (i.e. after t. began to rise), no headache or thirst : 10 P.M. 
t. 104° -6, p. 86, skin dry, feels chilly, some headache (acme of the relapse). 20th 
day. — I A.M. t. 102°, p. 84, headache more, no chills, no thirst: 4A.M. t. 99''"4. 
p. 88, no chills or thirst, headache less, no sweating at any time in this attack : 7 A.M. 
t. 98 '-6, p. 74, skin dry, tongue florid moist, less headache, no thirst, or giddiness, 
or pains ; to relieve the headache she induced vomiting by tickling the fauces, vomit 
a green liquid : she looks a little worn, but walks about, appetite is less, the spleen 
is unchanged, being neither enlarged nor tender : blood-spirillum not seen. The t. 
declined a little lower, at i p.m. being 97° -8, p. 66. For the next day, it was still 
taken frequently, but there was no sign of change ; convalescence was slow for the 
remaining few days she stayed in hospital. Vide Charts 9 and 9A, Plate IV. at the 
end. 

With evidence like the above, I am disposed to interpret afresh three 
oj- four cases seen at the beginning of my researches, which displayed 
che spirillum at periodic dates corresponding to those of first and second 
relapse, when no perceptible rise of temperature appeared at m. and e. 
thermometer readings. These instances were, at the time, regarded as 
showing a relapse might be truly ' latent ; ' but it now seems most pro- 
bable that owing to the long intervals of observation, some pyrexial dis- 
turbance had been overlooked, and that the ' latency ' was apparent only. 
Whether or not visible infection can ever pass without involving tem- 
pernture-changes, has yet to be conclusively settled ; but, at present, 
evidenre tends to show that the specific recurrence in man is always 



PYREXIA — VARIETIES OF RELAPSE. 1 6/ 

attended with some degree of pyrexia, or, in other words, that spirillar 
blood-contamination always culminates in pyrexial perturbation, however 
brief. 

Another topic requires notice here : thus, at many occult late re- 
lapses and at some of earlier date, I have found in blood-specimens pre- 
pared by the Albrecht-method and staining, minute filaments having a 
close resemblance to immature spirilla, so far as the latter may be 
imagined to exist {vide Chapter on the Blood) : and I gained the im- 
pression that a partial development of the spirillum may attend a partial 
development of relapse-phenomena. 

Deferred Relapse. — It is uncertain whether or not a latent or sup- 
pressed relapse, is ever followed by a recurrence of unmistakeable 
character; and more difficulties surround this subject than might be 
supposed, on account of the wide limits of apyretic intervals or known 
incubation-periods. Thus, as regards the first apyretic period, its mean 
duration being 7-8 days, 11 or 12 days have occasionally been witnessed 
in hospital to lapse before the first febrile recurrence (not to mention the 
longer time mentioned by a few patients), this interval allowing of re- 
infection from without and the conversion of a possible abortive into a 
relapsing attack. Nor is this merely imaginary, for I know that one 
spirillar infection does not preclude another even at early date ; and in 
the medical wards contagion may be said to have been always possible. 
I have not, hoAvever, been able to establish such an event as now sup- 
posed, nor am I at present acquainted with a method by which its reality 
could be demonstrated. Respecting the later and longer apyretic periods, 
their mean duration being even more variable, the difficulties of proof 
are not lessened. The following case much interested me : — 

Case XXXVII. — F., 30, one of a group admitted with specific disease, previously 
had fever for a month (?) ; tliere was high pyrexia (t. 106° '8, p. 132) and critical fall 
4 days later : for 7 days no febrile disturbance whatever, then a brief rise to 100°, 
p. 74, then a decline for 6 days and a second rise, prolonged, low (max. t. 101° -8, 
p. 80) and gradually declining, when she left hospital. The temperature was taken 
several times daily during these two perturbations and the dried blood submitted to 
scrutiny by the acetic acid method ; it remains doubtful if the spirillum as commonly 
recognised was ever present, only filaments resembling it were noted about the acme 
of first rise, and beginning of the second more pronounced perturbation : more I can- 
not say, from not knowing the significance of appearances seen. It should be stated 
that the woman suffered severely, at first ; and that the spleen was distinctly implicated 
in the later temperature movements. 

Febrile paroxysms occurring as late as 2 or 3 weeks after the first 
crisis, with an intervening apyretic period quite undisturbed, could not 
be regarded as relapses proper, for they were always non-spirillar. 

Spurious relapses. — In course of enquiry the spirillum fever was 
found to be attended with febrile paroxysms, not apparently due to local 
irritation or malarious influence, which, though periodic in date and in 
other respects resembling brief relapses, yet did not display the spirillum. 
They were seen in about 15 p.c. of all cases and commonly in place of 
third or second relapse when of i day's duration, and when lasting longer 
as second or first relapses. As seeming to be ' spurious,' i.e. non-specific 
quoad recognisable blood-contamination, they attracted particular atten- 
tion : most occurred before I was aware of improved methods of blood- 



1 68 SPIRILLUM FEVER. 

scrutiny, and I must now regard such instances as only showing the 
practical difficulties once met with in correctly interpreting the clinical 
phenomena of spirillum fever. It is almost certain such paroxysms were 
not spurious ; but in justice to observations made with care, I am bound 
to remark that the fully-grown blood-parasite may not represent the sole 
infective agent of this disease. 

Other occasional febrile phenomena. — In practice, the first or second 
specific attack sometimes appears to be preceded by one or more mild, 
isolated paroxysms of uncertain character : that the spirillum may not 
then be found is only a conditional argument against the specific nature 
of such preliminary paroxysms, since it is often not to be seen in fresh 
blood at the beginning of an indubitable relapse, or even of a clear in- 
vasion : and the real question is, whether or not the blood-scrutiny has 
been an adequate one. 

Also at the close of mvasion and relapse, a more or less detached 
febrile paroxysm may take place, which is open to varied interpretation 
as either belonging to the specific attack or supervening like residual 
fever : here, too, much depends on the skill and patience of the ob- 
server, it being understood that once the spirillum has disappeared at 
acme or crisis, it never reappears until date of next recurrence. 

Varieties of Apyretic intervals. — An acquaintance with this subject 
becomes useful, when patients do not come early under notice Varia- 
tions concern the length, general level and course of inter-febrile periods, 
all of which differ considerably : rallying after critical fall whilst usually 
prompt, may be either delayed or gradually effected ; mid-course presents 
either a quasi-normal temperature or one somewhat depressed, a sus- 
tained elevation above normal being indicative of local complication ; at 
the end, when relapse is near, either no visible change occurs, or a slight 
depression contemporary with first advent of the spirillum, or a slight 
rise. These remarks apply to the aspect of ordinary Charts. ' 

Repeated Attacks. — Before comparative experiment had proved that 
one infection does not either preclude from or predispose to a second, 
on even early date, I had at hospital seen instances of repeated attacks 
amongst men. Occasionally new comers gave a history of such earlier 
illnesses, but the opportunity of witnessing successive fresh attacks was 
necessarily rare : how many repetitions may happen in the same subject, 
is unknown. Second infections may or may not differ from the first, in 
their general manifestation. 

Case XXXVIII. — M., 30, Mussulman immigrant, was admitted 2 July, 1877, during 
the invasion-attack, which after 6 days was followed by a marked relapse of 5 days' dura- 
tion (spirillum so rare as not to be seen in the fresh blood), the succeeding apyretic 
period was normal for 12 entire days seen. Five weeks later, he was admitted at end of 
a smart fresh invasion-attack; and there was no relapse during 17 days after crisis. 

' Necessarily I have consulted Wunderlich (Syd. Soc. Transl. 1871) as a recognised 
authority on Pyrexias, and also later authors ; the result being a reliance on my own data. 
Respecting these apyretic intervals. Dr. Wunderlich observes 'let the course of tempera- 
ture be what it will, there almost always occurs about the middle (of the first interval) a 
brief, sharply-pointed elevation of temperature . . . freedom from fever soon recurs and 
very often it is complete only after this episodal elevation ; ' this hardly accords with ex- 
perience at Bombay of nnconiplicated cases, but in connection with secondary fever and 
local inflainnialion, interruptions of apyre.xia become frequent. 



REPETITIONS OF INFECTION. 1 69 

Case XXXIX. -M., 22, native medical pupil, one of eleven infected in the wards 
of the same hospital, was admitted 10 June, 1877, ^^ fi'^st day of first attack ; a sharp 
rebound followed in 3-4 days after crisis (no spirillum), and 5 days later another 
febrile perturbation of undetermined character : 17 days afterwards he left hospital. 
Nine weeks later he was readmitted with a second attack also caught in the wards, 
and the invasion was about as pronounced as before : after 4 days there occurred a 
febrile movement of undetermined character (no spirillum and no apparent complica- 
tion), for 15 days long' r the temperature was nearly normal, there being noted only a 
slight rise on the 9th day — blood not examined. In this instance a certain similarity 
is noticeable in the charts of the successive attacks : the lad never suffered again, 
though still exposed to infection. 

The first attack which I incurred in December 1877, was of the Re- 
lapsing kind and tolerably severe (spirillum in the marked recurrence so 
sparse as not to be visible to myself in fresh blood) : the next illness in 
February, 1 880, was milder and of the abortive form : both events followed 
inoculation at autopsies ; and I may add that a Native lad co-infected 
on the last occasion, underwent an abortive attack resembling my own. 



I/O SPIRILLUM FEVER. 



CHAPTER V. 

COMPLICATIONS OF SPIRILLUM FEVER. 

SECONDARY FEVER, AFFECTIONS OF THE NERVOUS, RESPIRATORY, CIR- 
CULATING AND DIGESTIVE SYSTEMS, OF THE URINARY ORGANS ; 
ABORTION. 

These comprise the more unusual phenomena associated with febrile 
attacks, and they may be said to consist essentially of {a) intensified 
ordinary symptoms and states — e.g. delirium, hiccup, hepatic, splenic and 
renal changes ; jaundice, diarrhoea, sudamina (see also Chapter III. for 
the three last-named) ; {b) local inflammations also more or less directly 
arising from the infection : e.g. meningitis, ophthalmitis ; bronchitis, 
pneumonia ; parotitis, pharyngitis, gastritis, enteritis, colitis ; nephritis. 
(c) accidents in the circulation ; as haemorrhages, cutaneous, mucous, 
serous and parenchymatous ; thrombosis : abortion. And lastly {d) 
post-critical febrile reaction. Other examples imperfectly recognisable 
during life, are mentioned in the description of Anatomical Lesions. 

Almost all complications date from the acme of fever or ensuing 
crisis, when general symptoms become most acute and abrupt blood- 
changes occur : they are commonest at close of invasion, and tend to 
reappear with relapse : their severity is very diverse, and some, as 
cerebral haemorrhage and pneumonia, are common causes of death. 

As every pronounced illness displays some peculiar features due to 
the predominance of one or more symptoms, it may be said that com- 
plications are always imminent ; and their discrimination from the more 
ordinary clinical phenomena, is often matter of judgment. Also indica- 
tive of their common origin, is the usual concurrence of two or more of 
these phenomena, it rarely happening that any complication exists alone ; 
and to the varying combinations occurring, are referable many remark- 
able types of the spirillar disease. I do not here allude to the congeries 
of symptoms known as the typhoid state, or to the general and special 
modifications of spirillum fever described below in Chapter VII. 

Combinations. — For convenience, each complication must be con- 
sidered apart ; but it is clinically important to recognise the chief con- 
junctions of phenomena, as follows : — Ordinary severe cases ; besides 
hepatic, gastric and splenic derangement, delirium, bronchitis and diar- 
rhoea occur as a frequent group of milder complications. Jaundice, 
hiccup, broncho-pneumonia, dysentery and parotitis ; splenitis, with bron- 
chitis and diarrhoea at relapse. In Case X. are named symptoms often 
concurrent ; and in a Hindoo subject about the same date, I noted 
jaundice with hepatitis, delirium, petechiae, sudamina and hiccup, form- 



COMPLICATIONS — SECONDARY FEVER. I/I 

ing a nearly similar type of fever ; this fact pointing to a prevailing epi- 
demic character during 1878. I would also remark that groups of cases 
may have peculiar aspects : thus amongst Ward-servants, some striking 
combinations of symptoms occurred — such as vomiting, epistaxis, jaun- 
dice, irregular distribution of heat, delirium with twitchings, cough, splenic 
uneasiness ; and in another case, bronchitis, marked perturbatio critica, 
albuminuria, delirium, jaundice and transient pneumonia. Native medical 
pupils showed epistaxis, hepatitis, melaena, vomiting, diarrhoea ; and 
vomiting, delirium, jaundice, hepatitis, petechia, cough, pleurisy and 
burning sensation in the feet. Unusual events noted amongst hospital 
patients seized in the wards did not materially differ from the above, 
except on the few occasions when their original ailment was acute enough 
to intrude its own symptoms : dysentery was, however, more frequent or 
marked. Cases with evident local inflammation, and the casualties, are 
not included in these synopses ; and to other parts of this work, I must 
refer for detailed illustrations of the principle under comment : details 
are many and varied. 

The combinations of main symptoms furnish the i72signia of disease, 
and upon them as much as on the predominance of one or two special 
signs, must rest both diagnosis and prognosis. Synthesis as well as 
analysis of bed-side data, is needful for accurate conception (imago) of 
a specific fever ; and a chief object of the memoranda detailed below, 
and elsewhere, is to aid in such conception as is intuitively formed in 
the mind of the observer, and becomes his idea of the spirillum disease. 

For purpose of description, complications are arranged in physio- 
logical order, but I begin with one of general character and especial 
interest. 

I. Secondary Fever. — Clinical experience at Bombay has necessi- 
tated the separate consideration of this subject. By the term Secondary 
fever [synonyms: — consecutive or residual fever, and reaction or re- 
bound of temperature), is meant non-specific pyrexia often supervening 
at acme and crisis of Invasion, seldomer of first Relapse.' At first 
sight, such sequelar pyrexia appeared to be strictly ' idiopathic ' ; but 
there is reason to connect it with marked blood-changes, and with paren- 
chymatous lesion of the larger abdominal glands. 

Like several other complications, it arises by many gradations from 
ordinary symptoms ; and it was seen at two periods, viz. at acme {a), as 
practically continuous with specific fever ; and {b) following the crisis, 
as a form of febrile reaction. 

{a.) Sub-acmal Pyrexia. — In ordinary cases fever begins to subside 
immediately after the acme of attack, when the general symptoms already 
described are most acute ; but occasionally it persists for a time, entail- 
ing increased risk of life and often causing death. Fever thus prolong- 
ing uninterruptedly the pyrexial state, is associated with the advent of 

1 It was perhaps owing to my habit of constantly examining the blood, that the present 
discrimination arose ; possibly, too, the phenomena here described were commoner than 
usual at Bombay, yet on looking over the numerous temperature-charts furnished within 
the last 10 years by recent observers, I now perceive that a similar feature attends the 
spirillum fever of Europe, although it does not seem to have been alike interpreted. At 
an earlier date, Prof. Wunderlich evidently referred to it as forming an ' amphibolic stage ' 
such as is not peculiar to relapsing fever. See Chapter on Pathology below. 



1/2 SPIRILLUM FEVER. 

remarkable blood changes : see Chapter on the Blood, Section III., and 
for clinical illustration, Cases XV. and XVI. Chapter III. of this Section. 
It is not irrelevant to point out, that the declining pyrexia at ' lysis ' 
sometimes appears to be of this character. 

Generally, such post-acmal pyrexia does not last for more than a few 
hours ; and since it is practically continuous with the specific fever of 
illness, not being distinguishable therefrom except by means of micro- 
scopical blood-examination, the discrimination here attempted may be 
regarded as a needless refinement. But believing as I do, every marked 
change in the aspect of the blood to be of clinical significance, the 
present distinction becomes both valid and useful ; for it is founded in 
reality, and is also of prognostic import, in so far that experience teaches 
when after disappearance of the blood-spirillum high pyrexia persists, 
the patient's life is in imminent danger. 

Two cases were seen at the close of first relapse, which displayed a 
distinct sinking of temperature corresponding to critical decline, prior 
to the final rise, and may therefore be regarded as transitional to the 
next group. That last seen (M., 46) presented symptoms like those of 
acme ; and after death, I found the lungs permeated with serum and 
fine air-bubbles, spleen 20 ozs. and in it several infarcts, liver large and 
flabby, congestion (? extravasation) at lower end of ileum. 

{b.) Secondary fever in form of Rebound temperature after the crisis. 
The date of reaction varies: — ^i. Immediate rebound. After the in- 
vasion-attack, especially, and in milder form, not uncommon ; see an 
instance in the chart of Case X. : of more pronounced degree, the fol- 
lowing is an illustration : — 

Case XL. — M., 19, famine-immigrant though in fair condition ; admitted on 5th 
day of invasion, e. t. 105°, p. 124, spirilla many, no peculiar symptoms, the liver and 
spleen not appearing much implicated ; some cough ; dysentery at the acme two 
days later, and critical fall on estimated 8th day of attack, e. t. 96° '2, p. 80, sweating 
profuse. The same evening chills with return of pyrexia, and next m. t. I04°'8, 
p. 116, skin dry, headache, pains in loins and legs, bowels quiet, liver and spleen 
unaffected, cough continues, second day after crisis, m. t. 102° '6, p. 112, hepatic 
dullness upwards not increased, but some fulness and tenderness in the right hypo- 
chondrium, tongue moist, two stools ; third day, m. t. 99°'4, p. 82, skin dry, some 
jaundice, three loose stools ; fourth day, slight increase of fever, m. t. 101°, p. 106, 
tongue moist, cough less, four stools, hepatic uneasiness not increased ; during the 
next three days fever rose and then declined, being remittent in type, and not ending 
with sweats : the hepatic soreness was not attended with distinct enlargement, 
bowels now quiet, and no other local lesion appeared in connection with this sequelar 
pyrexia : notes and blood-examination by Mr. S. A. Vide Chart No. 20, Plate VI. ; 
it will be found to resemble, at early course, some charts of more indubitable compli- 
cations — e.g. that of pneumonia No. 26. 

The following cases are examples of immediate rebound and death: — 

Case XLI. — M., 38, medical subordinate, stout habit but healthy, contracted fever 
at an autopsy : the attack was tolerably pronounced ; bilious vomiting and cough 
were present, liver and spleen not much implicated, no epigastric tenderness ; 6th 
and last day, 7 a.m. t. 104°, p. 124, some delirium in the night, urine passed 
involuntarily, no vomiting, headache or distress, tongue dry and brown ; 9 a.m., the 
crisis has taken place, t. 97°, p. extremely feeble and intermitting, about 100 ; heart's 
.sounds nearly inaudible, impulse absent : yet collapse not entire, pupils normal, eyes 
bright and indicative (^f his hearing and jwrtly understanding what is said to him : 
there were constant tremors of the limbs and the hands fumbled at the hot water 



COMPLICATIONS — SECONDARY FEVER. 173 

bottles ; some small livid spots now appeared on the arms and legs, and front of 
chest ; an hour later, reaction had begun and at 11-30 a.m. the t. had risen 8° or 
to lo5°"6, p. very rapid and small, skin moist, the unconsciousness and tremors in- 
creased, the face became livid and death took place in f hr. ; hence a period of five 
hours included acme, crisis and rebound, all these events being witnessed because 
the patient was under special notice ; under ordinary circumstances, the later phe- 
nomena might have been overlooked. Vide Chart 18, Plate V. 

Case XLII.— M., 35, admitted for malarious fever, and a few days after recover)' 
appeared specific fever, caught in the ward : the attack was pronounced and lasted 
5 days ; blood-contamination abundant, general and local symptoms not peculiar. On 
fifth day, m. t. 104° -6, p. 130, countenance anxious, skin moistened and unusually 
sensitive all over, pains of the joints, no fresh spots, abdomen not distended, bowels 
relaxed, tenderness in bnth hypochondria preventing sleep : e t. io5°-4, p. 120, tongue 
moist, skin dry. Last day, m. t. 96°, p. 80, crisis in the night with sweats, skin now 
dry, breathing quiet, a few fresh spots of eruption, no pains, depression ; spirillum 
disappeared : e. t. 105°, p. 150, moderate volume and soft, respirations 60; fever 
returned with chills about noon, no headache, has pains of the loins and knees, much 
thirst, skin dry, vomited twice, no particular distre-s, no fresh spots ; blood free 
from spirillum ; it is stated he remained in this state during the night, quietly sinking 
next morning under persistent fever. At autopsy, no jaundice; head — a little 
slightly-turbid serum in arachnoid, with gelatinous streaks on dura mater, no in- 
creased vascularity, or petechiae ; hearr appeared healthy ; lower lobe of both lungs 
much engorged with blood ; liver 62 ozs., termed healthy, spleen 19 ozs., dark, 
firm ; kidnies healthy looking ; mucous membrane of stomach of pink hue, no ex- 
travasatii .n, a few small petechise in the j junum. It happened that an hour or two 
later, I inspected some parts, and found on cut surface of spleen the large pale areas 
indicative of ' infarcts '—exposure to the air bringing out their different aspect to 
rest of spleen-pulp. Since the engorged .--tate of the lungs may have been due mainly 

to 'fever,' the splenic degeneration seemed significant of fatal blood-deterioration. 

Vide Chart 19, Pl.\te V. 

During my comparative experiinents on the Monkey, this prompt 
febrile rebound was recognised in both mild and severe form, its 
resemblance to the phenomenon in man being very close : when most 
pronounced, it ended in death 3 times out of 4. The temperature 
attained usually exceeded that of the prior specific fever, as was the case 
in the human subject ; the type of fever was somewhat remitted, and 
its course could be better traced by the more frequent thermometer 
readings practicable in the monkey ; these showing a prompt decline 
before death, not, I think, always occurring in man. At 3 autopsies I 
found the mucous membrane of stomach and small intestines to be 
congested or mflamed ; the spleen enlarged, infants being not noted ; 
such coarser changes are not peculiar. See Appendix on Experimental 
Pathology, No i, with Chart. 

Commonly the secondary fever does not arise until from 12 to 
48 hours after crisis, and may be deferred to the 3rd day or later ; it 
then varies in intensity, though still sometimes exceeding the spirillar 
pyrexia it follows, and its consequences are then seldom serious. This 
kind of reaction happened in about 10 per cent, of ordinary survivino- 
cases, seen at all periods of the epidemic, amongst all races and castes, 
and after both abortive and relapsing attacks ; bemg sometimes noted 
after invasion alone, but commonest and most pronounced when 
following the fully-developed first relapse : 2nd and 3rd recurrences 
were rarely thus attended, or the fever might in them remain undis- 
tinguishable. Its onset was abrupt, course more or less paroxysmal, 
and the decline more or less prompt, but rarely smking below the 



174 SPIRILLUM FEVER. 

normal level of body-heat : the pyrexia was acuminated or remitting, 
maximum ioi°-io5 ° or higher ; duration from a few hours to several 
days. The attendant symptoms were those of pyrexia, with oppression 
or weakness ; local derangement might remain unnoticed, and when 
observed in the longer cases particularly, abdominal or chest symptoms 
seemed rather to follow the fever as consequences of it : splenic, 
hepatic or bronchitic uneasiness prolonged beyond the crisis, were not 
necessarily exacerbated at this time ; with unusual debility, a quasi- 
typhous state was occasionally seen. The pulse seldom quickened 
proportionately to rise of temperature ; but with diarrhoea, delirium, 
and signs of local irritation, actual or imminent, the pulse was apt to be 
more excited ; initiating chills, and at the end sweats, were often 
wanting. Secondary fever was commonly preceded by a pronounced 
specific attack, and the mean t. at crisis in 27 cases was 96° 7 ; but as 
the rebound followed also less marked crises and was absent in the 
deepest ones known, its occurrence was not in strict proportion to the 
prior state of depression. Some of the most striking examples were 
seen in young subjects, though not limited to such ; almost all patients 
were males ; the general condition was fair. The attendant visible 
blood-changes were neither notable nor uniform, the blood-spirillum 
invariably being absent ; and this negative character sufficiently dis- 
tinguishes the fever from that of specific attacks. 

Repetitions of the rebound were rare ; and the interpretation of 
most uncomplicated febrile events after 2nd true relapse being difficult, 
such are apt to be confounded with later recurrences. 

Case XLIII. — M., 30, Mussulman weaver (family affected) admitted at close of 
invasion, at the decline of which there followed a level first apyretic interval of 9 
days. The relapse was very pronounced, duiation 5 days, crisis with fall of 10° '8, but 
little sweating, there was depression yet not collapse, t. 95°, p. 78, small, weak : 
rallying did not begin till after 48 hours, when the progressof the case was asfollows: — 
second interval, second m. t. 98°- 4, p. 96, no headach". much pain in loins and stag- 
gering gait, slept, one stool ; urine free, 1015, no sediment, no albumen, chlorides ^ 
vol. : e. t. loi^, p. 84, no fresh symptoms with this rise. Third day, m. t. I04°"4, 
p. 102 : no such distress as attended the specific fever, or sign of local complication 
except some diarrhoea, skin moist, heart's action very feeble, no eruption, he slept 
well, pains in loins and knees ; urine copious, chlorides ^ vol. : e. t. 105° -8, p. 102, 
full, soft, no spleen or liver tenderness, no stool, tongue moist, skin supple, much 
thirst, little headache, pains and much debility. Fourth day, m. t. 104°, p. 120, no dis- 
tress, headache slight, skin dry, sudamina have appeared on chest and abdomen (front), 
tongue coated, moist, indented at margins by the teeth, he slept, pupils normal, urine 
plentiful and clear, no implication of liver or spleen apparent ; e. t. 104° -4, p. r'20, 
he lies quiet, some headache, much aching in loins and knees, and cannot get up from 
weakness : spleen now somewhat enlarged, not tender ; liver unchanged, no other 
apparent complication ; considerable thirst, tongue moist, skin moist, urine free, 1015, 
chlorides ^ vol., no albumen. Fifth day, decline of fever, m. t. 100° 4, p. 90, no 
stool, abdomen rather tympanitic, no distress, tongue moist, fre>h sudamina, sleep 
indifferent, some headache and pains ; urine acid, loio, chlorides ^ vol., slight 
cloudiness on addition of nitric acid (cold test) : e. t. 101°, p. 96, feeble, no sweats, 
he is rallying. Sixth day, m. t. Q9°'8, p. 84, slept only in latter part of night, less 
headache, fresh sudamina, the pains continue : urine free, 1005, chlorides ^ vol., 
slight indications of albumen by cold test ; e. t. 101°, p. 96 ; last day, m. t. 98°, 
p. 72, no headache, sweats on forehead, he slept, some dry cough much pain in 
loins and weakness : urine as before ; e. t. 98°-2, p. 90, some sweating on f rehead. 
The temp, declined further to 97°, p. 84, no fresh symptoms appeared, but the pains 
in the loins (muscular) became severer for a time ; the urine at once lost all (races of 
albumen : sciatica, diarrho'-a, increased appetite, attended the ensuing convalescence. 



COMPLICATIONS — SECONDARY FEVER. ' 1 75 

The blood was continuously and carefully scrutinised with the negative results shown 
in the chart : white corpuscles were plentiful. Vide Chart 21, Plate VI. 

This man's daughter of 12, admitted just after him, displayed a striking inter- 
mittent rebound of 8 days' duration, which was attended with delirium, splenic and 
hepatic implication, and some bronchitis ; but, as with her father, no fresh complica- 
tion or lasting lesion was present : the specific attack seen in hospital was probably a 
first relapse, like his : the child's mother had lately died of fever. 

Case XLIV. — M., 12, admitted 3 days before the close of a well-marked specific 
attack, which seemed to be first Relapse : liver and spleen implication not unusually 
marked and not persistent after the crisis ; 3rd day of post-critical apyrexia, m. t. 
97°"8, p. 86 ; the same night secondary fever set in sharply, and next e. t. io5°-4, p. 140 
(t. higher than ever before seen), yet no distress ; some constipation, headache, thirst, 
general aching pains ; 4th day, vomiting with slight enlargement a^ain of liver and 
spleen ; then increased thirst, want of sleep, slight hepatic and splenic tenderness, 
indisposition for food, vomiting, deafness, tendency to diarrhoea ; on the 7th day, 
pyrexia, remittent all along, declined to 99°, p. 102, he was weak but less oppressed ; 
fever, however, at once returned, though less pronounced, remitting daily, and on the 
9th morning t. declining to 98° "4, with some sweats. During this period there were 
no fresh symptoms, but rather a subsidence of those previously existing : a second 
and final recurrence lasting 6 or 7 days, of nightly, ague-like paroxysms, now took 
place ; at the end subsidence to 97°"5, p. 76 ; no symptoms of urgency : two sub- 
sidiary rises followed and 3 weeks' unchecked convalescence. No blood-spirillum 
throughout the first 15 days of this sequelar pyrexia, or at the last (Mr. S. A) : no 
obvious cause of the fever in any local lesion. Vide Chart 22, Plate VI. 

Several cases of anomalous fever seen after 7 or 10 days' illness 
outside hospital, doubtless had their correct explanation in examples 
like above, the symptoms present being best or only understood on such 
interpretation : often there was a history of association with relatives or 
friends, known to be affected with relapsing fever. 

This subject is of great practical importance ; and hardly less interest- 
ing were instances like the following, which indicates the possibility of 
deferred febrile results of infection, and forms a link connecting such 
results with ordinary sequelae. 

Case XLV. — M. , 16, whose chart shows a well-defined febrile attack of negative 
blood-character, coining on in hospital 21 days after the crisis of demonstrated spirillum 
fever ; it lasted 9 days, being pronounced and fairly sustained. No local lesion was 
detected beyond some early splenic and hepatic fulness and tenderness, bowels rather 
relaxed, no pains, a general soreness of the body at first ; afterwards some numbness 
of the legs and feet, also deafness ; there was slight cough ; final convalescence. 
The connection of this attack with the original spirillar infection may be dubious, yet 
I note that the youth continued to be low and delirious long after the specific crisis, 
or until 5 or 6 days before this new event, with which a similar kind of delirium at 
once returned. 

Amongst complicated and fatal cases to be hereafter discussed, 
there were examples of prompt rebound attended with cerebral 
haemorrhage, enteritis and, oftener, pneumonia. An instance before me 
shows that the pleuro-pneuinonia and splenic enlargement found after 
death, did not probably supervene until ten days, at soonest, after 
secondary fever had set in. As even frequently, this consecutive 
pyrexia seemed to become the cause of such local signs as might 
appear, its occasional origin in a faulty state of the blood can hardly 
be doubtful. 

Summary. — Non-spirillar fever immediately consecutive to the 
specific pyrexia of Invasion or Relapse, when sustained and prolonged 
(for even a few hours) was seen only in fatal cases. 



1/6 SPIRILLUM FEVER. 

It is probable some instances of defervescence by lysis were examples 
of this consecutive pyrexia, which was not sustained but declined 
gradually : they, too, were of serious import. 

A decline of temperature resembling brief crisis, may intervene 
between specific acme and this secondary fever ; and Case XLI. 
above quoted, indicates the likelihood of such intermediate event being 
more frequent than is stated. 

Then follows the series of more distinctly separated and longer 
deferred secondary fever, which though not seldom prominent, were 
seldom known to prove fatal ; and, lastly, there are instances which 
might be regarded as sequelar. 

Diagnosis of Secondary Fever. — This rests upon the history and 
previous known course of the case, on the absence of local symptoms 
and lesions at all proportionate with the promptness and height of the 
pyrexia ; and lastly, upon the absence of spirillar blood-contamination. 
I should add that the fact alone of such consecutive fever occurring in 
the lower animal — a Xx\x&fera naturce — is proof of its not being, in man, 
an accidental conjunction of a civilisation fever (such as typhus or 
enteric) ; and evidence is wanting that the monkey is liable to ordinary 
malarial infection. 

Complications affecting the Nervous System. — These are important, 
because of the office of the structures involved ; and they are frequent, 
because of the unusual vascularity of the brain and its membranes. 

2. Delirium. — The term is employed here to mean temporary mental 
derangement, attended with either excitement or depression of the 
frame. This symptom was noted in over i6 per cent, of observations 
made upon a series of 140 detailed cases seen throughout the epidemic, 
in both survivors and the dying ; it was associated solely with the febrile 
event, as either accompaniment or sequel. It was never remarked prior 
to the commencement of specific fever, or until the 4th or 5th day of 
the severer first attack, thenceforward daily becommg more common 
(mean frequency now 13 p. c.) ; at the acme and immediately ensuing 
critical fall, delirium was noted in 28 p. c. of cases ; and during the suc- 
ceeding interval amongst survivors it became uncommon, being also 
limited to the first day or two after the crisis (about 5 p. c. of cases) : 
amongst the casualties at this last period (complications usually present), it 
was noted in 20 per cent. During the first relapse, and more so during 
later recurrences in which, too, the fever was much briefer, delirium was 
rarely seen, and then almost solely at the close of attack ; in cases fatal 
now, it appeared in 14 p. c. of instances. At all later non-specific 
periods this symptom was extremely rare, being present only with febrile 
complications. Generally, the first signs and milder degrees of delirium 
being liable to oversight, it is probable my notes should sometimes be 
both ante-dated and supplemented, especially as the entries were mostly 
made only twice a day ; and it is within my personal experience that 
transient delirium at the acme, was such as a hospital attendant might 
not regard. 

Clinical forms. — For precision I would arrange these as follows :- • 



COMPLICATIONS — DELIRIUM. 177 

a. Febrile delirium: varieties — i. During high specific fever. 2. At 
secondary fever or the rebound. 3. \M h symptomatic pyrexia. 4. 
With the typhoid state at lytic decline of specific fever, b. Non-febrile 
delirium supervening during, at the end of, or shortly after the crisis of 
specific fever. It is to be understood that some of these varieties may, 
in the same case, be seen severally, or in chronological continuity during 
illness ; and also that in successive attacks the delirium may not be of 
the same form. 

Clinical characters. — a. I did not perceive any constant difference 
in cases where the fever was specific {i.e. attended by spirillar blood- 
contamination), and where it was non-specific or due to co-existent 
local inflammation : under all conditions the typhoid state was threaten- 
ing, imminent, or actually present, when delirium became noticeable. 
The symptom here resembled that in other ' fevers ' ; it earliest appeared 
and was most marked at night, when pyrexia usually exacerbates : at 
first active in character it tended to become low and muttering ; 
pure sleeplessness often preceded, and drowsiness or stupor might 
follow this cerebral manifestation. Usually, it promptly subsided with 
the fall ; but might persist longer, especially if complications were 
present. 

b. Post-febrile delirium is attendant on the depression which ensues 
during or soon after, the critical fall of spirillum fever : it is a remark- 
able phenomenon, in its more pronounced form coming on abruptly 
day or night, and resembling either a brief maniacal impulse, or a more 
sustained state of active and continuous delirium of i. 2 or 3 days' 
duration : in both cases the predominating idea seemed to be fear, 
leading to corresponding aspect and acts ; there was sleeplessness, in- 
voluntary evacuations and obstinate refusal of food and medicine : re- 
covery usually ensued upon repose, and might be prompt and permanent. 
The milder forms were commonest (possibly not infrequent), displaying 
a tractable, chattering, busy delirium coincident with decline of tem- 
perature and pulse, and not lasting more than a few hours : about 10 
p. c. of my last series of cases showed this kind of mental derangement 
at crisis, and usually at night-time, first or only. 

Other details may be seen in the cases below ; the association of 
headache with delirium was ofiener than not recorded, their conjunction 
varying : the pulse may not be rapid with active febrile delirium, its 
relationship also being unfixed. 

Febrile delirium was of highly variable degree in the same or similar 
cases, the active state being seldom pronounced or prolonged. _ That of 
collapse may be very violent (even furious) and sustained, as in mania ; 
or restless, vagarious, sleepless, liable to sudden exacerbation ; or no 
more than mere incoherence and restlessness : destruction of clothing, 
bedding, and seeming intolerance of interference or confinement (? due 
to terror) were common expressive acts ; the general aspect and state 
being such as not witnessed in any ' fevers ' in India, I am acquainted 
with. 

Among the mildest and incipient degrees of delirium, may be men- 
tioned the causeless sleeplessness or terrifying dreams occasionally 
named by patients (old as well as young). 

Both forms were liable to remission (even intermission) and exacer- 



178 SPIRILLUM FEVER. 

bation : the first changing with the febrile state and general condition of 
the patient ; the second altering less, with the less variable depression 
and increasing debility. 

In neither form occurred any proper sequel, the febrile ending in 
recovery or death ; the post-febrile in prompt recovery, or death (rarely), 
and lastly, in mania or mental imbecility more or less persistent. 

Age. — Young persons or adults were the usual subjects : of 9 youths 
with mean age of 22, 4 had delirium, and of 13 persons with mean age 
28, 6 showed this symptom, whilst of 14 cases of mean age over 30, 
5 only had it : all these instances belonged to the hospital contagion 
series of 1877. 

Sex. — Disproportionately oftenest in males. 

General condition. — Febrile delirium was commonest in originally 
weak subjects, or those enfeebled by want and fever : the non-febrile 
form occurred in even robust males, yet no rule appeared here. 

Type of disease. — Low or prolonged fever with lysis-tendency was 
especially attended with ordinary delirium ; high and pronounced fever 
with marked crisis, was oftener the precedent of the maniacal form. 

From my notes it seems that amongst Hindoo immigrants in 1877, 
maniacal excitement was commonest ; whilst in 1878 and afterwards, 
among Mussulman weavers, the febrile delirium proper. 

Correlated symptoms.— Febrile delirium in the sthenic seemed to 
bear some relationship to the intensity of pyrexia, in the asthenic to 
frequency and feebleness of pulse, with other signs of low febrile state. 
The post-febrile form was seen only when the body-heat and pulse 
were greatly reduced, at and after the critical fall. I was, however, 
much impressed with its absence in some instances of extreme depres- 
sion, as narrated elsewhere ; and it holds no fixed relationship, when 
present, with degrees of bodily weakness. It is also to be noted that 
marked icteroid aspect, with even copious eruptions as of typhus, may 
not be attended with delirium, when ' fever ' is mild, brief or uncompli- 
cated. Severe and even fatal local complications may not be attended 
with delirium ; once it was slight with meningitis in an old man. See 
also the cases below. 

Diagnosis. — Febrile delirium occurring so early as the 5th, 6th or 
7th day, even when complications are threatening, should lead to care- 
ful microscopic examination of the blood ; the history and circum- 
stances of the case also claiming attention : in itself, the delirium is not 
peculiar. 

In Bombay I never saw post-febrile mania after ' agues ' or ' remit- 
tents,' at all resembling that above described, as occurring in subjects 
liable to the contagion of famine-fever : it is true that in one instance 
of suicidal dehrium, the blood had furnished negative data, yet to my 
mind the case was not clearly not one of this fever, for many circum- 
stances had to be considered, which only a practical acquaintance with 
spirillum fever could, in absence of adequate blood-examinations, inter- 
pret aright. 

The resemblance of specific febrile collapse to the algide stage of 
true cholera, was more apparent than real ; one point of distinction 
being its occasional complication with a form of active delirium never 
seen in cholera, so far as known at Bombay. 



COMPLICATIONS — DELIRIUM. 1 79 

Prognostic import. — Febrile delirium does not begin earlier in 
specific attacks which end fatally, either soon or later on ; but it is 
decidedly commoner in such attacks ; thus, amongst survivors the ratio 
showing delirium during the last 3 or 4 days of invasion being 13 or 14 
p. c, it was 23 p. c. amongst fatal cases : all these patients being chiefly 
Hindoos seen in 1877 and '79. During 1878, however, among Mussul- 
man weavers, febrile delirium was as frequent in survivors as in the 
dying, the general type of fever here being ' low ' ; hence the bad augury 
of this symptom will depend partly upon the general character and 
tendency of epidemic fever. Cases fatal in 1877 were usually at- 
tended with local complication (pneumonia oftenest), and this circum- 
stance it is important to remember. 

All 6 patients seen dying at end of first relapse had been delirious 
at close of invasion-attack ; but only 3 of them showed delirium just 
before death ; these died from exhaustion, the brain being found pale 
twice ; 3 had no delirium in the relapse, who died from cerebral haemor- 
rhage, pneumonia and pericarditis : in these last the previous mental 
disturbance was slighter than in the others. 

Notwithstanding the intensity of spirillum fever, its brief duration 
and tendency to complete subsidence render the prognosis of uncom- 
plicated cases marked by delirium, less unfavourable than in continued 
fevers, or even remittents. 

As a rule, post-febrile mania is even strikingly free from bad augury, 
due care being taken to prevent the patient injuring himself: some in- 
stances of quick rallying excited the most welcome surprise. When 
prolonged, however, it becomes a sign of organic degeneration, leading 
to final exhaustion. 

Following delirium may be noted deafness, anaesthesia, or nerve- 
irritation evidenced by morbid sensations in the limbs ; pains may be 
severe : yet all these symptoms come on also without preceding mental 
disturbance. 

Illustrative cases.' — These will be limited to instances of delirium 
either with co-existing spirillum fever, or immediately following it : the 
connection of this symptom with non-specific pyrexia, whether of re- 
action or symptomatic of local lesion, presenting no peculiarity of date 
and character. Febrile delirium : — 

Case XLVI. — M., 34, admitted on reputed 6th day of invasion, apparently at acme 
of attack, t. 104° -6, much enlargement and tenderness of liver and spleen, respiration 
hurried, but no lung complication detected ; much exhaustion, and low, muttering 
delirium ; a marked critical fall ensued on the same night, with little sweating ; 
delirium subsided, headache and depression persisting 24 hours longer ; rallying slow, 



1 Two sad instances met with prior to recognition of the blood-spirillum and therefore 
not included in the text, were the following : they happened within three davs of each 
other. — M., 25, admitted with high fever of 4 days' duration, on 7th morning the critical 
fall of 6^-6 to 97°'6, much depression, pupils contracted, slight dt-Lrium the previous evening 
and at crisis ; an eruption of pink spots (compared to typhoid spots) ; second morning 
after fall, t. 98°-4, no sleep after midnight and some headache ; at about 9 A.M. he went 
to the latrine and passing by a staircase reached the hospital verandah, and threw him- 
self over, being killed on the spot. M. , 40, admitted at the close of fever, much depressed ; 
temp, next morning 97°"6 (lysis decline), some pink spots on trunk ; he was lying quietly 
on his cot at 8^ a. m. when I passed, and a few minutes later suddenly got up, ran to the 
vt-randah and threw himself over, meeting instant death. I had all fever-patients at once 
removed to the ground-floor wards, for this experience was peculiar; it confirmed my 
opinion that famine-fever was present in Bombay. 

N 2 



l8o SPIRILLUM FEVER. 

no eruption. After 7 days a well marked relapse occurred, lasting 5 days and ending 
with a great fall of temperature, the depression at its end continuing 48 hours ; in the 
last 1 2 hours of this time delirium came on at night, the man wandering about, with 
no memory of places, t. 97°-8°, p. 76-86, and respirations declining to 15 p. min. : 
this mental debility slowly subsided in 2 days, and convalescence was fair : a second 
relapse folio > ed, with further rises of temperature, but no mor.' delirium. 

Case XLVII. — M., 25, admitted on reputed 12th day of invasion, depressed; dis- 
tress and dyspnoea, t. l02°-4, p. 1 10, respirations 70. there was active but tractable 
delirium in the night: at 4 P.M. iht pcj-ttirlhitio critica with rigors during which his cot 
shook, crisis in the night, and next morning only some drowsiness left. At the close 
of apyretic interval and succeeding pronounced relapse, there was again a distinct 
critical exacerbation, during which time he became delirious an ' semi-conscious, being 
veiy low and in much distress (I suspected clots in the heart), yet these symptoms 
all passed away with the crisis, in a few hours. 

Like the last, this case strongly indicated the connection of delirium with the 
peculiar systemic disturbance occurring at close of spirillum fever, when blood-changes 
occur. 

Case XLVII f. — M., 15, admtted on 4th day of invasion with high fever ; next 
day there was active delirium increasing at night, eyes not injected, no headache ; 
10 gr. doses of Chloral and Potass. Brom. had no effect; with decline of t. prior to the 
acme, delirium ceased and there were sweats ; it returned with the acme and persisted 
with the crisis, until near its end, although chloral in larger doses was given. The 
lad soon rallied, and 8 days after a pronounced relapse of 4 days' duration set in ; 
there was again mental disturbance and excitement at midnight, during the acme, 
ceasing with the great fall of temperature. Another lad of 15, showed violent delirium 
at the close and rather gradual decline of specific fever, which was uncontrolled by 
morphia injections : so two young men of 18 and 22, who had pulmonic congestion at 
the same time, entire relief ensuing: with crisis : and so a man of 25, in the course of 
whose single attack, epistaxis repeatedly occurred, on 7th morning t. 102°, p. 130, 
dicrotic ; depression, restlessness, delirium, body hot, limbs cold and convulsively 
twitching ; at 3 P.M. sweats, with crisis and prompt relief. 

The morbid anatomy of febrile delirium is, as yet, but imperfectly 
made out ; brain-lesions of coarser aspect are sometimes wanting alto- 
gether, or are slight {vide Case XIII.) after death with febrile delirium ; 
and with much lesion, functional disturbance may not be active. 

Cases. — F., 23, was admitted in a state of active delirium, moaning, semi- 
conscious • t. 105° '6, p. 140, full and firm ; became quite insensible and died in 
24 h'lurs. There was cerebral haemorrhage (arachnoidal), with lobular congestion of 

the lungs. 

M., 32, admitted near acme, when t. 105'^, p. 120, eyes injected, headache, skin 
dry ; epistaxis followed and next morning t. 100°, p. lOO, small and feeble, no head- 
ache ; delirium in the night, with continued decline o!" temp, next day, t. 98^, p 100, 
feeble ; when he became unconscious, restless and dyspnoeic, dying shortly. There 
were h'semorrhagic petechise in the heart, lungs not collapsed, brain pale. 

M., 14, admitted near end of invasion, being prostrate and delirious ; pupils 
dilated and sluggish, urine passed in bed, death in 5 hours. The brain was pale, wet 
and soft. 

Typhoid state in connection with spirillar infection. — M., 30, brought 
to hospital with a history of previous attack : is depressed, incoherent, 
at times semi-conscious and passing into the state of coma-vigil : eyes 
sunken, sordes on lips and teeth, tongue dry, brown, red at sides and 
tip ; no abnormal sounds in chest : tenderness over the liver, spleen 
and r. iliac region : evacuations passed involuntarily, the stools semi- 
consistent, t. ioo°-ioi°, rising on the 3rd and last morning to io3°-6 
when he became unconscious and died. The blood then contained 
swarms of large spirilla, many large pale cells, some of which were 
vacuolated ; there were also lars;e endothelial cells with fatty granules 



COMPLICATIONS — DELIRIUM. l8l 

in them. Cerebral meningeal haemorrhage, petechise elsewhere and 
congestion of lower end of ileum, peculiar changes in liver and spleen ; 
the heart and lungs unchanged. 

Mental perturbation first appearing with critical subsidence of fever, 
may be brief and limited to the beginning of crisis (of which several 
examples are before me), or it might come on with, or last until, the end 
of decline ; and, finally, sometimes it supervened still later. 

Case XLIX. — F., 40, admitted at close of invasion-attack, crisis the following 
night with a decline of 10° -4 F. ; on first day of fall, m. t. 93° '6, p. 68; continued 
decline on second day to 93° (estimated), p. 72; she had now become incoherent and 
restless, and on the next night was very turbulent : on third day a slight rise to 96°, 
p. 74, delirium persisting; on fourth day t. 94° "6 to 95° "4, p. 72; on fifth day 
t. 96° -2, p. 82, she had slept until 2 a.m., the delirium hen reappearing; on the 
following day the temp, rose to 97°, p. 80, and there had not been further disturbance. 
During this time Bromide Potass, and Chloral Hydr. had been freely given, with 
stimulants local and general. 

Case L. — M., 25. For upwards of 10 days had high fever outside hospital which 
left him with profuse sweating, and so weak that on admission 3 days later, he could 
not stand : some jaundice and several pink spots on the body : he then began to 
improve. Four days after entering h spital, the relapse set in with chills ; it was 
pronounced (t. on three days 105°, p. 130-140) and lasted 6 days : fresh spots 
appeared : on the last day there was a slight remission prior to e. exacerbation, 
vomiting, no delirium : in the following night crisis occurred and del rium came on, 
with a decline of 8° 8, a d pulsations 44. First day of fall m. t 96°, p. 96, much' 
exhaustion, skin clammy, tongue pale, shrunken, tremulous, moist ; pupils sluggish, 
of normal dimensions ; stools passed in bed, urine retained ; no fresh eruption : ' he 
lies in a peculiar condition of collapse with tremors and mental derangement, mouth 
open, eyes bright ; is now quiet, but during the night when the fever left {i.e. after 
9 P.M.) he was sleepless, restless and attempting to run away; respirations 30, rather 
gasping ; he cannot speak above a whisper, and he picks at his teeth, as if feeling 
something there ' (MS. notes on case). Urine drawn by catheter 20 ozs., loii, high- 
coloured, slightly acid, clear and no sediment on standing : after a few hours' rest in 
conical vessel, there were no particles visible under microscope except a few epithelial 
scales and bacteria. Stimulants given. Vesp. t. 95°, p. no, very feeble and small ; 
skin moist, has rallied a little though temp, lower (pulse not slower) ; delirium less, and 
he takes food ; much thirst, no urine passed : catheter ordered. Second day — m.t. 96°, 
p. 108, very small ; was excited during the night running about the ward : now still 
prostrate, pallid, but not sinking into the bed ; pupils normal, skin dry, sordes on the 
teeth, tongue dryish, and not protruded fully, evacuations passed in bed, no eruption ; 
the liver and spleen rather full and tender. Unne drawn— sp. gr. ion, acid, high- 
coloured, clouded, but not deposiiing sediment, chlorides reduced to ^, bile-pigment 
much, albumen none by heat and acid, slight traces (?) by acid alone : after standing, 
under microscope, some epithelial, mucus, and blood corpuscles (due to friction of 
catheter), many small bacteria moving and quiescent, some large, clouded or granular 
cells, nucleated, tint yellowish, nature uncertain, some granular masses like zooglasa ; 
nothing more. Vesp. t. 95°, p. 120, skin clammy, he is rest 'ess, getting up and 
trying to run away, tears bed-clothes and chatters incoherently, pupils of normal aspect, 
slight injection of conjunctiva, no sensible heat of head, expression of face vacant and 
brows contracted : pulse and heart's systole extremely feeble, he cannot stand erect : 
sordes, shallow breathing, involuntary evacuation of urine, slight cedfina of feet : 
petechial spots have appeared on abdomen, r. shoulder, 1. chest, bright red, slightly 
raised, and not quite effaced on pressure. Chloral in addition oidered. Third day — 
m. t. 98°, p. 114, .'■mall, soft, flickering: somewhat less delirious, but still talks 
indistinctly and incoherently; skin soft, dry; tongue brown, but inclined to be moist; 
abdomen distended, some tenderness over spleen, none over the liver; pupils normal, 
eyes slightly congested, ciaves for water ; no stool, urine passed in bed and drawn off; 
he takes nourishment, slept until n P.M., after then lay awake but quieter than 
before ; still can hardly stand : fresh spots on the wrists, none on back or lower 
limbs, those of yesterday are fainter, less raised and not affected by pressure. Urine — 



I 82 SPIRILLUM FEVER, 

sp. gr. 1015, acid, chlorides a tmce, bile acids and pigment present, no albumen or 
sugar: no sediment. Vesp. — t. 99°, p. 1 14, less feeble, still mutters to himself but 
understands when spoken to : takes food and medicine ; tongue becoming moist, 
passed urine voluntarily. Next day — m. t. 98°"4, p. 102, fair volume, slept without 
the sedative, appears dull, but is more rational, urine free : after this date his recovery 
was fail ly progressive, no return of fever, the osdema of the feet had not subsided in the 
fortnight he remaii ed in hospital. This case received particular attention, and was 
regarded as shov\ing that mtntal disturbance is not necessarily due to visible urinary 
derangement. 

Delirium may not supe.vene until after the crisis has passed and the 
minimum temperature recorded. 

Case LI. — M., 40, also Mussulman, a weak subject, on admission gave a history 
of invasion-attack, with a first relapse then present ; 3 days afterwards the ciitical fall 
to 94^ F. (estimated), p. 60, with extreme depression, no urine for 24 hours, then 
found to be clear, 1022, free from albumen ; pupils rather contracted, intellect clear : 
a few pink spots : he then rallied promptly and completely as usual. On 5th day of 
second apyretic interval intermitting fever appeared, ushering in the second relapse (no 
spirillum), and on 7th day continuous pyrexia began (spirillum present) which lasted 
4 days, ending with a perttirbatio critica (t. 104° '2) and followed with a decline next 
m. ; t. then 94° (estimate), p. 102 : sweating occurred, and a few fresh spots appeared ; 
vesp. t. 94° '4, p. 92, some headache. Second day of fall— m. t. 94°, p. 108; slept, 
still some 1 eadache and pains ; vesp. — t. 96° -5, p. 72, much headache, with pains in 
loins and knees : at 7 p.m. he became delirious and ran away from the ward, was 
brought back and placed in a side room. Third day — m. t. 98°, p. 90, said to have 
■slept after being locked up, is now (7 a.m.) silent and morose, but when approached 
shouts and become excited as if from fear : veiy weak, pupils somewhat dilated, no 
injection of eyes or heat of scalp : vesp. — sweating; is in the same maniacal state, 
refusing food and medicine, and not replying to questions, mutters incoherently to 
himself, and resists the least attempt at control, becoming very violent : Potass. Brom. 
and Chloral were administered. Fourth day — has slept and is rational, t. 98'''5, p. 88 
(sitting), pupils normal, some deafness, still headache and pains in loins : Uiinr also 
normal, loio, chlorides ^ volume, no albumen present ; from this date he rallied 
quickly and completely, the only complaints for a time being slight headache, buzzing 
in the ears, deafness and debility : in lo days he was convalescent, and for a longer 
period had no return of fever. 

Case LII. — F., 30, admitted 5th day of invasion-attack, which was pronounced 
and marked with daily febrile exacerbations and remissions: crisis on 9th day was prompt 
but not sudden or extreme; e. t. 95°"2, p. 88, resp. 26 (in ni. 22 only), skin dry, 
tongue coated white, no headache or delirium, or thirst or pains, is very weak, much 
abdominal tenderness, spleen going down, much cough, sputum bronchitic, stools 
natural. First day of apyretic interval, m. t. 98°'2, p. 80, resp. 24, skin dry, tongue 
white and dry, no headache, thirst, no appetite, bowels costive, no pains anywhere, 
spleen felt but not tender ; was delirious at night, but now seems tranquil : vesp. — 
t. 98°, p. 80, resp. 24, skin dry, bowels moved ; wanders in talk and manner, occa- 
sionally becomes excited and has to be placed in confinement. Next day, she had 
slept after Chloral, and the mental state was quieter ; t. and p. natural : next day 
slept without Chloral, now had pains in all the limbs but no headache, the delirium 
henceforward ceased. 

Cape LIII. — M., 28, admitted on 5th day of invasion, symptoms pronounced, 
marked crisis on 7th morning, t. 96° -4, p. 92, much sweating last night, no headache 
and great relief to the symptoms generally; vesp.— t. ioi°'6, p. 108, a rebound of 
fever preceded by chills at 3 P.M., no headache, much thirst, hepatic pain gone, 
spleen still enlarged and painful on coughing ; no spirillum in the blood. First day 
of apyretic interval : the secondary fever has subsided, m. t. 97°, p. 88, no headache, 
slight thirst slight cough, no pains, spleen tender still, no sweats : vesp. — t. 97°'4. 
p. 66. Second day after crisis: m.t. 97°"8, p. 88 no headache or thirst, tongue moist 
and coated at the 1 ack, no cough or pain in chest, no pains in limbs, spleen tender ; 
bowels mo\ ed ; he liecame delirious last night at 10, and did not sleep ; now exhibits 
a busy, active state, picking at the bed clothes and getting up, though he is tractable ; 
pupils rather dilated, a watery discharge from the eyes, pulse weak, small and 



COMPLICATIONS — MANIA. 183 

irregular, systole feeble: the spleen is tender on firm pressure only. Vtsp. t. 96°, 
p. 74, skin moist, he slept after Chloral and Digitalis. Next day there was still 
some depression, t. 97° "6, p. 70, but no further dehrium : the splenic enlargement 
was probably old. 

The full morbid anatomy of this form of delirium has yet to be re- 
vealed. 

Case LIV. — M., 40, admitted towards close of invasion which subsided by lysis 
to t. 97° -2, p. 88, there were pink spots, cough, hiccup, and no other unusual symp- 
toms : day after completed fall, t. 97° -6, p. 88, little change noted ; second day— t. 
still 97° '6, p. 102, and now some delirium with restlessness, respirations 24 shallow, 
haemoptysis (scanty) and moist sounds only heard on auscultation of chest : death. 
Brain conge ted only : pneumonia of part of one lung : characteristic changes in liver, 
spleen and kidney. Here delirium at fall was associated with latent pneumonia ; 
and there is reason to suppose similar complication to be not unusual, with both febrile 
and post-febrile mental disturbance: see also some of the cases above. 

3. Meiital Hebetude, Mania, Bementia.— It was not unusual after 
specinc infection to see a certain degree of mental feebleness, not ex- 
plicable by the general debility alone ; various prior conditions doubt- 
less contributing to this result, but not always in apparent connection 
with head symptoms. One case (M., 22, after first relapse) displayed 
with mental depression and feebleness, marked frontal headache pre- 
venting sleep, a feeble circulation and tendency to diarrhoea not con- 
trolled by treatment. Another instance of prolonged low delirium 
tending to become chronic and indicating a connection with more than 
functional disturbance, was the following :— M., 16, before and after crisis 
(? of relapse) delirium was the most prominent symptom, in diminished 
degree it persisted for seventeen days, with temp, and pulse nearly at 
normal ; at first deafness (not of extrinsic origin), numbness of legs and 
toes and a burning sensation in the palms and soles, which lasted for a few 
days only : on twenty-first day after crisis, a smart and sustained febrile 
attack, apparently due to secondary fever, return of delirium : conva- 
lescence slow. There were many spirilla in the blood on his admission. 
Some further stages of changes possibly due to a common lesion, are 
illustrated by the instances following. 

Case LV. — M., 30, a weak subject, admitted at end of invasion pro' ably ter- 
minating by lysis (many spirilla with t. 99° "2) : next day, t. 97°, p. 80, restless 
delirium came on in the night, with depression, pupils active, evacuations involuntary; 
e. t. 100°, p. 103, a slight rebound of fever, no enlargement of liver or spleen. First day 
of interval, t. 99°, p. loo, no sleep, delirium at night, tremors, eyes injected, the typhoid 
state threatens : second day, indifferent sleep, no de'irium in morning, still debility ; 
so third and fourth days, the same low state with incoherency and but slight evening 
febrile exacerbations (not of pulse) ; so till t' e nth day after first fall, m. t. 98°-6, 
p. no (quickened now), slept, took food, scalp said to be warm, is dull and listless ; 
vesp. t. loi°-8, p. 120 — the relapse beginning. Second day— m. t. 99°"4, p. 120, 
slept, is m(ire alert than yesterday (the fever seeming to act as a stimulus) : vesp. t. 
io3°-4, p. 120, feeble and irritable, no sleep : third day— A. M. t. 104°, p. 150, skin 
moist, slept a little (sedatives given), eyes injected, head hot, much depression, sordes 
about the mouth; is again chattering and delirious: urine free: vesp. t. i03°-2, 
p. 154, sweats, no stools, takes food, spleen enlarged and tender: delirium active — 
many spirilla in the blood. Fall — m. t. 97° -6, p. barely perceptible ; collapse present : 
vesp. t, 100" -2, p. 128, copious sweating, a rebound of fever. The second apyretic 
stage now followed, lasting S days till death : te p. level, commonly below normal 
(extremes 98°-4 and 96°'4), pulse above normal (92 to 108) and very feeble : his 
mental state was that of depression, amounting even to dementia, and ending in 



I 84 SPIRILLUM FEVER. 

unconsciousness; his bodily condition prostrate and emaciating day by day. _ At the 
autopsy — some opaciiy of arachnoid, pa^e and collapsed lungs, pallid heart, dissemi- 
nated fatty patches in the liver, spleen unaltered, so the kidnies ; congestion of the 
ctecum. 

Case LVI. — The following case was regarded as one of brain lesion after 
spirillum fever : family history good : no bad habits. M., 1 8, brought in a very 
weak state with a history tf 15 da)s' fever, delirium having come on during its course : 
t. i03°'6, p. 130, feeble, organs in chest and abdomen apparently normal; there is a 
state of passive delirium, with rational intervals when the patient understands what is 
said, pointing to the- foiehead as seat of pain. I formd the blood-plasma clouded, 
fibrillation indistinct, free protoplasm in clumps, several active blood-spirilla : also in 
the sputum a .spirillum sluggish and a little larger, with other parasitic growths ; 
some salivary corpuscles contained dividing nuclei and swarms of mobile granules. 
The fever declined by lysis on the 3rd day ; t. 96° 5, p. lOO, and thenceforward the 
temp, rising to normal fluctuated but little for the 12 weeks he stayed in hospital : the 
pulse declined after crisis, as. usual, and remained slow and weak. The lad's mental 
condition after improving a little, soon passed into that of imbecility ; pupils normal, 
hearing good, sj sleep and appetite ; but taciturnity and inattention to calls of nature, 
with much emaciation and profound ansemia : final prospects of the worst. 

4. Deafness, Noi.ses in the Ear, Earache. — None of these symptoms 
were common, or appeared of special significance. Deafness was noted 
chiefly at the critical fall, and oftenest at the end of first relapse (one- 
seventh of cases), then attending other signs of exhaustion and feeble- 
ness of the circulation : it seldom lasted longer than two or three days : 
an illustration is given m Case No. IX. It also sometimes came on at 
the acme of fever, with heaviness of the head and tendency to drowsi- 
ness : and it was occasionally noted in connection with typhus-like 
symptoms amongst the Mussulman weavers, yet not often or in propor- 
tion to the apparent cerebral exhaustion or oppression ; in such instances 
it might be one-sided, and persist for some time. It was not most 
frequent in the fatal cases. The symptom was also noted later after 
crisis, in connection with increasing debility, giddiness, slow-pulse, ex- 
haustion after delirium and secondary fever. It was sometimes present 
during the complication of sore throat, tonsillitis and parotitis. Extreme 
or permanent deafness was not seen ; and from this summary the usual 
conditions of its presence will be evident : deafness due to treatment by 
the cinchona alkaloids is here excluded. 

Tinnitus aurium ; buzzing in the ears was, in all cases, associated with 
weak circulations and functional derangements of the other special 
senses. 

Otitis and otorrha-a were noted in a few women and children, and 
had probably existed prior to febrile attack : in a lad of 8, left earache 
was a premonitory sign of the brief relapse, not persisting : in a woman 
of 25 admitted at close of invasion, there was a peculiar nodding, tre- 
mulous movement of the head in possible connection with pain and then 
watery discharge from the left ear ; after crisis a slight febrile movement 
in apparent connection with the ear symptom ; and with a striking par- 
oxysmal re]a]>se, brief return of the tremors ; convalescence was slow. 
Earache has been known to come on after a second relapse, together 
with boils and pustules on the legs. 

5. TCumbness and Soreness of Uands and Feet. — The subjective sen- 
sations complained of by patients, pertained rarely to diminished sen.si- 
bility of the soles and palms, but rather to exalted or perverted feeling — 



COMPLICATIONS -ALTERED SENSATIONS. 1 8$ 

variousl}' defined as tingling, formication, pins-and-needles, or commonest 
of all, a burning sensation, much increased on pressure being applied to 
the skin. 

Perhaps 3-4 per cent, of subjects were thus affected, or more, since 
modified hyperesthesia sometimes long eluded notice, becoming 
evident only when the feet were accidentally placed to the ground, or 
the hands made to grasp firmly : it was seldomer rioted in the fatal cases, 
being usually a pht;noment)n sequelar to fever. Perverted sensations 
were rarely detected (if ever) during invasion-attack, seldom earlier than 
a week after first crisis (or about the time of first relapse), and 9-12 days 
after second crisis (about the date of second relapse) : when a febrile 
recurrence occurred they were neither suspended nor increased thereby ; 
and in the absence of a distinct first or second relapse, they still might 
be well marked : they have been noted towards the close 'of both 
apyretic periods, in the same subject. 

Their intensity seemed to vary much; patients sometimes complaining 
bitterly of the discomfort, loss of sleep, and crippUng entailed : no exact 
data, however, are available, and I am unable to estimate the variety of 
common sensation, most or oftenest aftected : numbness was indicated 
seldom at beginning, and never as a sequel of the hypersesthesia, but 
precise information is needed here. Duration — usually a few days only ; 
sometimes 3 weeks, or as long as the patient could be induced to stay in 
hospital : site — the soles of the feet always ; often (perhaps generally) 
the palms of the hands also, either first or for a briefer period, and 
seldom so severely as the feet, the hands always recovering first : it is 
probable the hypersesthesia extended to the digits, sometimes the dor- 
sum, and also included deeper-seated parts ; some patients distinctly 
naming pains shooting upwards, along nerve-trunks (?) : no visible or 
temperature changes were remarked in the parts. The morbid sensa- 
tions were always increased on pressure or movement, and usually in- 
creased for a time before subsiding, a diurnal exacerbation after noon 
bemg noted, and more or less distinct remission towards early morning. 

The majority of 12 cases analysed were young men : paupers ; all 
the subjects were weakly, the circulation esoecially being feeble and 
heart's action sometimes irregular : cases were seen at all periods of the 
epidemic, and after fever mild or (oftener) pronounced, abortive or re- 
lapsing. Other complications were rarely present ; the state of the blood 
not visibly peculiar : signs of contemporary defective nerve-action were 
usual, such as pains in the limbs then or previously, giddiness, swimming 
or flashes before the eyes, muscse, tinnitus aurium, neuralgic pains in 
the head ; dilated pupils. 

Diagnosis. — Suspicion of some connection with the cerebro-spinal 
centres, was not verified, the nerve-lesion seeming evidently transitory ; 
though patients sometimes felt the ground as 'velvety,' yet they distin- 
guished the shape of objects with closed eyes, and could walk fairly : in 
two cases I noted the gait was striking and peculiar ; for the men not 
daring to put the whole sole to the ground, walked on their heels, as if 
the ground were on fire. 

Prognosis. — Was not unfavourable, so far as known : but the final 
result in some severer examples could not be witnessed. 

The anatomical characters and intimate cause of these phenomena 
being unknown, their real value can be only surmised : inference from 



I 86 SPIRILLUM FEVER. 

common site (oftenest the lower limbs) and observed occasional direct 
nervous connection, pointed to analogy with the characteristic febrile and 
post-febrile ' pains ' : a peculiarity was the frequent occurrence of these 
perverted sensations about the time of either latent or expected relapse, 
first and second. 

Other details are mentioned in the following illustrative memo- 
randa : — 

M., 40, weak subject, oedema of the feet, soreness of palms and soles on admission, 
near close of first (or second) attack, and persisting ; that in hands ceased after cris s 
in a few days ; ci'ippled by the foot-soreness, treading on a pebble would throw him 
down ; no starting of the limbs or pain in loins : ineffectual treatment by ergot, 
arsenic, strychnia : the heel gait for the 3 weeks he -tayed in hospital. 

M., 17, very weak, severe relapsing attack, and on 12th day of second post-febrile 
period oedema of feet, starting of the limbs, soreness of the feet, especially, which 
could not be put to the ground without pain, and then also involuntary contractions of 
the toes, augmenting the suffering : this experiment showed local hypersesthesia, at 
least, and I thought there might be increased irritability of the spinal centres : the 
whole foot was complained of : there had been -very severe aches of the usual kind 
before this came on : much relief in course of a fortnight from local use of aconite and 
administration of strychnia. 

M., 35, weak ; burning sensation came on during the relapse (blood full of very 
active spirilla), it also affected the eyeballs ; the ordinary pains were very severe : 
deferves ence gradual, and delirium supervene 1 : day after crisis, deafness afld numb- 
ness of the head, aching pains traceable along back of lower limbs (probably sciatic 
nerves) ; the same evening burning of the soles came on (and of palms also) : next day 
dysentery. 

M., 22, n>'mbne<s is named as preceding the soreness : hemicrania followed 8 days 
after the first relapse, and it would set-m also increased sensitiveness of some mucous 
surfaces, the ui^ethra being the seat of burning when urine passed, and the mouth when 
food was introduced: diarrhoea was present: the hear.'s action was feeble and irregular, 
sometimes intermittmg; no relief from nerve tonics. 

A general soreness of the surface of the body has been noted during 
specific fever ; the most striking instances I recollect, occurring in two 
patients who died at close of the attack, one of cerebral htemorrhage and 
the other, at rebound after crisis. 

Local Palsy. — Weakness and wasting of the deltoid muscle, has 
sometimes been noted. Instances were those of a stalwart man, whose 
right deltoid became enfeebled 4 days after a first relapse ; the injury did 
promise to be permanent : once the left muscle was affected, pain in the 
shoulder referred to the back of the joint and increasing towards night 
came on 10 days after an attack of fever supposed to be the first, a brief 
relapse followed ; relief was afforded by counter-irritation and strychnia. 
A patient with a history of relapsing fever, had the right deltoid so wasted 
as to render the arm almost useless ; only slight relief ensued on treat- 
ment. It is probable other muscles are liable to similar implication. 

6. Cereb' al Hsemorrl ag'e. — The frequency of this serious lesion in all 
its degrees is not precisely known ; because whilst the larger extravasa- 
tions could not be overlooked, the minuter, or incipient, forms need for 
their detection closer search than was usually practised. 

In 54 autojisies there were 8 examples of copious haemorrhage (^ of 
the whole) which are described below ; and, besides, in several other 
autopsies of pauper ' fever ' subjects admitted in a moribund state, similar 
lesion was found ; these instances, though generally concordant with the 
rest, being unverified by the microscope, are here excluded. 



COMPLICATIONS— CEREBRAL H.-EMORRHAGE. 1 8/ 

1. M., xt. 29, died 4th day (?) of first attack. Brain surface pallid above, venous 
congestion behind, with subarachnoid serous distension : haemorrhage (scarlet blood) 
into the cavity of the arachnoid, the clot compressed in a thin layer over the posterior 
lobes as far as t e fossse at the base of skull, its margin in front being well defined 
opposite the coronal suture ; tl ere were scantier clots also in the anterior and middle 
fossse. Brain-substance everywhere firm and healthy ; no internal congestion or 
unusual effusion : cranial nerves (including the va^t) unaltered ; so vessels and mem- 
branes, there being no sign of cerebral intiamm.tion or embolism. Pupils much con- 
tracted, restless delirium, rig rs or spasms, and partial insensibility some hours before 
death ; last noted temp. 101°, probably ri>ing ; p. 112. Spirilla in the blood. 

2. F., 23, d. 9th day of invasion. Great congestion of scalp: effusion of fluid 
blood into cavity of arachnoid, coagulating immediately on withdrawal; also along 
the course of middle cerebral arteries, beneath the arachnoid, in the Rolandian fissures. 
Intense congestion of veins at vertex of brain : brain-substance trm and dry, puncta 
va-culosa many ; no internal hatmorrhage, vena Galeni congested : autopsy 2 hours 
after death. Previously restless delirium and deepening insensibility, m( aning without 
stertor: last noted t. i05°-6, skin dry ; p. 140, full and firm. Large granule-cells in 
the blood. Pronounced jaundice. 

3. M., 35, died at critical fall of invasion, a few hours after admission ; t. 97°, 
p. imperceptible. Vascular turgescence and slight opacity of membranes ; reddish 
serum in arachnoid ; subarachnoid efiusion of blood opposite left parietal eminence and 
at base of middle and posterior lobes of brain, most on right side. No laceration of 
brain-substance, which everywhere seemed healthy. The typhoid state and restless- 
ness prior to death : pupils contracted. Spiiilla in the blood. 

4. M., 55, d. 5th day of firsi apyretic interval, pysemia (?) having set in : there was 
haemorrhage with suppuration beneath the arachnoid and clots in brain-sub tance : 
purulent foci in one lung. 

5. M., 30, d. 5th day (?acme) of first relapse. Scalp much congested, and so peri- 
cranium and endocranium : diffuse meningeal hsemorrh-ge over lateral and inferior 
surfaces of right hemisphere chiefly, in the pia-mater and traceable between the con- 
volutions along the middle cerebral artery. Elsewhere brain and membranes healthy : 
the a terial circle at base of brain was everywhere pervious. The temp, rose to I03°"6 
before ( eath, and the spirillum then disappeared. 

6. F., 20, dying after acme of relapse, suddenly. No congestion of scalp or brain 
membranes ; a large clot filled the vault over right hemisphere, reaching below to 
middle fossa and both posterior fossae, and in front nearly to the anterior fossa ; it 
was situated in the arachnoidal cavity, being somewhat adherent to the parietal dura- 
mater and above covered by a thin fibrinous layer towards the serous cavity, but 
not below where a fresher effusion of brighter red colour was seen, the aspect of the 
whole was recent, though not equally so. Left hemisphere alone intact. Brain- 
substance everywhere firm and healthy : velum interpositum pallid, ventricles empty : 
cranial nerves unaffected. Spinal ( ord healthy throughout, only a thin clot at upper 
part (for 3 inches) in, direct continuation with that in the posterior cranial fossae. 
There was an old injury to the skull on the left side unconnected, to all appearance, 
with this haemorrhage. Temp. 106° -2, and p. 140 the previous evening, falling next 
morning with decease, and the blood then became non-spirillar. 

7. M., 30, death at critical fall of relapse. Much dark grumous fluid blood was 
found in the sac of the arachnoid, chiefly on the left side : brain congested, substance 
firm ; no sign of inflammation or of arterial obstruction beyond a small pale nodule 
in one of the posterior communicating branches, not obstructing its channel. Pons 
and medulla healthy. Last temp, noted 95°, p. imperceptible : there was hemorrhagic 
pericarditis ; endocardium seemingly free : deep jaundice and intestinal blood-stasis. 
No spirillum at last, but previously abundant. 

8. F., 35, d. at undetermined stage of fever, moribund on admission, t. iOl'^-6. 
Congestion of membranes : a thin layer of blood in the subarachnoid space, and 
in the sac over the upper surface of both hemispheres ; no serous effusion ; brain-sub- 
stance moist ; a small quantity of tinged serum in the lateral ventricles. Deep jaundice 
and many spirilla in the blood. 

Remarks on the above series. — The amount of blood extravasated 
may have varied from 2 to 8 ounces : its site was always outside and 
mainly at the vertex, of the hemispheres ; 5 tim.es on both sides, 2 on 



I 88 SriRILLUM FEVER. 

right chiefly and i on the left, the effusion doubtless spreading or gravi- 
tating where least resistance : it was usually found both under and within 
the arachnoid, and since it might be present in the visceral subarachnoid 
space alone, it must have been poured out in the meshes of the pia-mater, 
afterwards forcing its way by laceration into the serous sac. The rarity 
of large extravasations within the brain-substance is noteworthy, only one 
instance being seen and that accompanied by inflammatory softening 
(vide No. 4 above). As to source of the blood, whilst various cerebral 
vessels at the base might be implicated, it was oftener possible to trace 
the effusion alongside the middle cerebral artery (here of the right side), 
the vertically ascending branches of which upon reaching their highest 
point at the upper surface of the hemispheres and there changing their 
direction to the transverse or descending, whilst comparatively unsup- 
ported in the loose meshes of the pia-mater, seemed to be specially liable 
to impaction and rupture ; and inasmuch as both larger trunks and minute 
interior vessels commonly escaped, it may be that those of a certain calibre 
or direction alone were predisposed to injury. Either only one effusion 
was indicated, or if there were several, one so large as clearly to account 
for the sudden death common to these cases. 

The aspect of the extra vasated blood was usually bright as if arterial ; 
once it was darker when suppuration co-existed ; generally coagulated 
once the blood was still fluid, and as autopsies were made as soon as 
practicable after death (mean interval 3 hours) sufficient time may not 
usually have elapsed for separation of the blood-fibrine. 

Additional particulars are furnished in the summaries of cases above, 
and such as relate to the blood itself are mentioned in Chapter I., Sec. III. 

Symptoms. — During fever, cerebral compression from the clot always 
caustd insensibility more or less complete ; yet even when established, 
the coma was not of the usual apoplectic character. In one typical 
instance the state was thus described — 3 hours after sudden onset of in- 
sensibility and 2 before death : she lies supine and tranquil, breathing 
50 per minute and very shallow ; no stertor ; no convulsions or rigidity 
of limbs, or spasm of the calm features ; sphincters relaxed ; pupils di- 
lated, fixed and equal ; temp, declining, now io2°"6, p. 144, full and 
bounding. (Vide Case No. 6, above.) 

In other instances unconsciousness was less active, and rather re- 
sembled that of shock with partial retention of irritability, as evinced on 
attempting to force open the mouth, or on firm pressure over the liver, 
spleen or epigastrium ; audible moaning was then a common symptom ; 
the pupils might be much contracted, even when haemorrhage had been 
considerable, the abdomen tympanitic and generally tender, the breathing 
hurried, the body-heat above natural (mean 103°) and pulse quick and 
small (mean 120) ; twice the critical fall was probably complete before 
death, mean t. 96'^, pulse 100 and feeble, or imperceptible. 

Special symptoms noted were lachrymation, ecchymosis of the con- 
junctiva, limited to one side ; alleged diarrhoea. 

At first the insensibility might not be continuous, alternating with 
delirium, and the state has also been compared with coma-vigil : eventu- 
ally deep coma or exhaustion supervened and decease in a few hours or 
not for a day or more, according to the amount and rai)idity of bleeding. 
It would seem that rofjious li;cn)(^rrhage, once and finally, was the rule \ 



COMPLICATIONS— CEREBRAL HAEMORRHAGE. I 89 

yet there were also signs of small effusions repeated at intervals, the brain 
symptoms being obscure or not perceived until by cumulation or a larger 
efflux, or superinduced inflammation, the lesion became insupportable. 
Five of the eight cases under analysis being admitted after attack, the 
premonitory signs of haemorrhage were imperfectly learnt ; in three of 
the five delirium was noted at first, but not in the instances (better pro- 
tected and nourished) seen in hospital throughout ; nor was headache 
present in the latter, and the coma is said to have come on suddenly in 
the night. Twitchings of the limbs was reported twice prior to attack, 
but once was possibly confounded with rigors of the perturbatio critica : 
particular injection of the eyeball or flushing of the face was seldom 
noted, and epistaxis not once. Symptoms truly antecedent were not 
ascertained. 

The date of hsemprrhage was always about the termination of specific 
fever : 3 times in 7 this pyrexia belonged to a relapse (probably the first) 
and it may have been oftener so ; on such occasions the invasion-attack 
ended by lysis ; the recurrent pyrexia was pronounced or prolonged, yet 
not peculiar. At the time of cerebral lesion the typhoid state had some- 
times supervened, but not necessarily ; in 3 of 8 cases there was pro- 
nounced jaundice : in 7 the spleen was found to be large, infarcted i, 
softened 5 ; it was small and exsanguine i : the liver was termed normal 4, 
large and pale 4 ; the kidnies congested, mottled (fatty) or spotted with 
haemorrhage, never granular ; the state of the urine was ascertained too 
seldom, but evidence of uraemia might certainly be wanting, and so of 
heart-implication (once only pericarditis) : the lungs showed lobular con- 
gestion or apoplexy twice, inflammatory nodules once, oftener a collapsed 
state : there were concurrent haemorrhagic petechiae in the sub-mucous 
intestinal surface 5 times, subserous (abdominal) 2, substernal i, and 
doubtless elsewhere unnoted : i was a case of haemorrhagic pericarditis 
and enteritis : scurvy was rare. 

The diagnosis of this complication is determined by the rules appli- 
cable to all similar lesions ; more particular stress being laid upon the 
rapid onset of cerebral compression, the speedily deepening coma, and 
the previous absence of head symptoms or marked toxaemia : the con- 
tracted state of the pupils, when present, would indicate surface cerebral 
irritation ; the character of the coma and its attendant symptoms, are 
also noteworthy. When the haemorrhagic effusion is small, the symptoms 
of compression may be almost replaced by those of irritation ; and in 
milder degree, these could hardly be distinguished from the effects of 
toxaemia. 

When meningitis supervenes on the haemorrhage, diagnosis may be 
very difficult : spontaneous meningitis was, however, extremely rare in 
spirillum fever ; and the remarkable limitation as to date (with attendant 
blood-changes) in cases of haemorrhage, should be borne in mind, as well 
as the frequency of lysis in the preceding or actual febrile attack. The 
correspondence of symptoms generally to those of acme stage of fever 
is noteworthy, and upon these the apoplexy supervenes as if by unfore- 
seen accident. 

Prognosis : highly unfavourable, no instance of recovery being known; 
and, I may add, no example of old arachnoidal effusion being found 
amongst the numerous autopsies of fever cases made during the epidemic 



190 SPIRILLUM FEVER. 

period. This statement does not, however, exclude the probabiUty of 
rare sequelar symptoms (e.g. of mental or motor derangement) in sur- 
vivors, being due to minute vascular lesion of the cerebral surface. 
Instances of minute cerebral haemorrhage are the following : — 

1. F., £et. 30 (healthy hospital matron, infected in her ward), minute spots over 
left parietal and right occipital convolutions and also in Sylvian fissure of r. side : 
pia-mater congested and loose, convolutons pale, wet and shrunken, slight opacity of 
arachnoid at base and some turbid serum : blood in cerebral arteries. 

2. M., aet. 30, congestion of membrane and slight opacity of arachnoid, effusion of 
turbid serum and rather softened brain-substance ; minute extravasations in some of 
the convolutions at the vertex and a Filaria more stunted than that of the blood 
found in one specimen (seemingly not accidental). 

3. M., ast. 34, brain pale and wet, spots of punctate hsemorrhage in convolutions 
along the two sides of the superior longitudinal fissure : no hsemorrhage in the mem- 
branes, subarachnoid fluid at base pinkish and arteries there distended : copious 
black vomit prior to death. 

4. M. , set. 23, congestion on surface, arteries at the base empty, but ramifications 
of the middle cerebral distended, substance of brain pale and softened ; in the 
crus cerebri above the locus niger a hsemorrhagic spot as large as a pea. 

5. M., ast. 24, congestion on surface with tinged serous effusion : on left side sub- 
arachnoid haemorrhage on under surface of posterior lobe ; none in Sylvian fissure : 
in the substance of the right superior peduncle of the cerebellum htemorrhagic 
specks : convolutions shrunken and easily unfolded, brain-substance wet and flabby. 

6. M., set. 25, minute extravasations beneath the dura-mater at the base of the 
skull ; some congestion of membranes and clear serous effusions : convolutions pale, 
wet, soft and shrunken. 

Remarks.— The above are but samples of a lesion, which doubtless 
was frequent in the large typhus-like class to which the cases belonged. 
The cerebral extravasations were small or minute, often numerous and 
scattered ; their seat not only in pia-mater on the superficies, but also, 
or alone, within brain-substance, grey or white, when others likp them 
may have been overlooked, in the same or similar cases. They v.'ere 
clearly due to rupture of small blood-vessels {vide Chapter on Morbid 
Histology). 

The spirillar-infection was at all times abundantly manifest ; external 
and internal petechise, or other blood-effusions were co-present ; death 
was never attributable to these minor lesions, yet it always occurred at 
the time when larger hsemorrhage was common, namely during the later 
days of the febrile attack, or immediately after its close ; no patient in 
this series survived until the relapse. Mean age of subjects 27 years ; 
one female ; general condition variable, and instances commonest amongst 
Mussulmans at later periods of the epidemic. 

Symptoms likely to follow these lesions could seldom be precisely 
dated, or dissociated from the typhoid or exhausted state supervening at 
the last : in 3 at least there were no head-symptoms beyond the drowsi- 
ness and delirium, not uncommon in severe cases of spirillum fever ; in 
2 the patients became unconscious and restless a few hours before death, 
with hurried breathing (40 to 50 per minute and no stertor) features pallid, 
pupils once of normal size, once equally contracted ; and in i case care- 
fully watched (No. i above) head-symptoms were noted in the following 
order : — vomiting after the 3rd day, restless and delirious after the 5th, 
pupils contracted on 6th, pete'^hial spots in skin, screaming, dilated and 
fixed pupils,'*abdomen tympanitic, eyes heavy and ronjimctivK injected; 



COMPLICATIONS — EPISTAXIS. I91 

head not hot on the 7th day : on 8th or last day, ecchymosis in upper 
half of ocular conjunctiva, right side, pupils much contracted, spasms of 
face and limbs, quick breathing (50, shallow, jerky), feeble action of 
heart, partial unconsciousness only ; probably coma at the end. When 
death in this series took place at the acme of fever, the mean temp, was 
1 04° -2, p. 125 : it happened twice during the fall. 

From the above summary it seems that whilst the cerebral lesion may 
not have been concerned in the production of prominent symptoms, its 
possible occurrence is worthy of recollection, since when present it must 
add to the dangers of the case or interfere with complete recovery : its 
effects will depend upon the site as well as degree : the pupils were 
normal twice (Nos. 2 and 3), finally more or less contracted thrice, state 
unknown once (No. 4), their state therefore being no positive guide to 
diagnosis of the injury. There was jaundice 5 times, 2 of deep hue 
{typhus biliosus) ; the general character of the symptoms approached to 
typhus in early prostration, feeble heart, eruption ; and, as regards the 
cerebrum, in the pale and flabby aspect of the convolutions : a similar 
state being found in other cases when petechice were present elsewhere 
than in the brain. The local changes in other organs were not peculiar, 
but like those seen in all severe examples of spirillum fever. 

7. Epistaxis. — Is rarer than might be expected considering the 
abruptness and force of the pyrexial changes, the frequently impoverished 
state of the blood, and the manifest troubles of the circulation : on the 
other hand, I note that epistaxis rarely occurs in agues, that the fever- 
patients were not usually scorbutic, and that circulation difficulties might 
be looked for on the arterial side of the capillaries. 

Bleeding from the anterior nares of a venous character was noted in 
5 or 6 p. c. of survivors, and in about 3 p. c. of casualties : it may have 
occurred somewhat more frequently. It was commonest during first or 
invasion-attacks (7-5 per cent), less common in relapses (275 p. c), 
and seen only once with complication (pleuro-pneumonia) during the 
first interval of specific attacks : of 1 2 selected instances, epistaxis was 
noted once on third day of invasion, 6 times at or near the close, and 
twice at critical fall ; once in the succeeding non-specific interval ; and 
twice during first relapse from third to fifth day : it occurred rather 
oftener during the day than at night. The bleeding was probably always 
venous, coming by oozing or quick welling from one or both nostrils, 
and soon setting : its estimated amount each time was a few drops to 6 
or 8 ounces ; its recurrence not usual or more than two or three times 
in the whole day, upon, at most, as many successive days : its source 
doubtless was the sub-mucous venous plexuses of the nares. Epistaxis 
was usually seen in young male adults, once in a child of 2^ years, 
once (in 12) in a woman of 30 yrs. : the subjects were the strong or 
weak, residents or immigrants, Hindoo or Mussulman ; none were par- 
ticularly scorbutic. Instances were seen throughout the epidemic, yet 
oftenest amongst the ill-fed weavers with fever of a low type ; the 
specific pyrexia was usually pronounced. 

It did not appear that epistaxis was necessarily associated with par- 
ticular head, chest or abdominal symptoms : only severe headache was 
noted in more than half the cases, and sometimes it was distinctly 



192 SPIRILLUM FEVER. 

relieved by the haemorrhage: deUrium was present with or soon after the 
bleeding in 5 of 12 cases, as often it was noted that the eyes (conjunc- 
tivae) were injected or unusually suffused, or the seat of burning sensa- 
tion, before or with the flux : thirst was sometimes excessive. It is 
noteworthy that epistaxis happened generally just before or at the acme 
of attack ; if coming on previously, it ceased then ; and more rarely was 
it seen during the perturbatio critica or actual crisis : the congestion of 
collapse did not lead to nasal haemorrhage : urgent vomiting was noted 
in some cases only. Epistaxis was not present during secondary fever, 
and once it attended a pulmonary complication after crisis (3rd day of 
ist interval) : jaundice of unusual intensity was never present : splenic 
or hepatic enlargement not unusually great. 

The diagnostic value of this symptom is but slight, yet Remittents 
and other common pyrexia were very rarely accompanied by bleeding 
from the nose. As to its prognostic import the occurrence of epistaxis 
wath marked perturbations of temperature, would point to the final stage 
or acme of fever being at hand ; though the cases were pronounced, 
yet the fatality being little beyond the mean, this symptom cannot be 
regarded as of bad augury. The bleeding either ceased spontaneously 
or was readily checked by cold ; the tampon was used but once in 1 2 
cases. Anatomical conditions — not ascertained : the attendant physio- 
logical state was doubtless excessive vascular turgescence of the Schnei- 
derian membrane ; the anastomotic connection with veins of the cere- 
brum or orbit, would account for occasional modification of head-symp- 
toms with epistaxis. Involuntary swallowing of the blood, with its 
subsequent reappearance, was borne in mind. As to conjunction with 
other passive haemorrhages, nasal bleeding was rarely associated with 
skin petechiae, never with haematemesis or haemoptysis, and only once in 
this series with ecchymosis of the conjunctiva. In one of two fatal cases 
it took place at the acme of invasion, lasting four hours ; death at the 
crisis, and at autopsy small haemorrhagic spots on the heart and not else- 
w^here. It would be easy to speculate on the significance of this symp- 
tom in particular cases, but when all instances are compared, it does 
not appear to pertain to a common state of the system, seeming rather 
incidental in its occurrence : an illustrative case is the following : — 

Case LVII. — M., 25, hospital servant in good condition, an abortive attack 
pronounced but uncomplicated ; seen throughout ; temp, moderate, pulse not un- 
usually quick till the end, then losing strength, headache and ocular congestion not 
excessive : repeated and rather copious bleeding from fourth to last day, but not at 
acme : Warburg's Tincture and Digitalis freely given : convalescence uninterrupted : 
eruption not noted. More significant, however, were instances like the following ; 
and especially Case LXXIK. below, which was overlooked in the above analysis. 
M., 27, had copious epistaxis at clo e of invasion outside hospital : on 3rd and 4th 
day of a well-marked relapse there was very free bleeding, just before and after a 
febrile exacerbation which either was itself, or foreshadowed, the acme, when the 
state of the blood undergoes a change : much headache before, not after, though the 
head was hot and temp, still high : no injection of eyes, or delirium : scanty eruption 
after cris's. 

8. Inflammation and Ecchymosis of Conjunctiva: Keratitis: Inflam- 
mation of the deeper Tissues of the Eyeball. — Coming near to these more 
palpable lesions, were seen also excessive lachrymation after crisis ; in- 
jection of the conjunctiva of a dull, passive hue; allered condition of 



COMPLICATIONS— OPHTHALMITIS- 1 93 

the pupils, usually dilatation, sometimes contraction, of undefined 
significance ; and the subjective sensations and fiinctional impairments 
of ocular vertigo, dark vision, flashes, muscae, night-blindness, diplopia, 
and oscillation of the globes : together with these symptoms, debility 
predominating. 

A sense of burning in the eyeballs has been noted at the height of 
fever, and also as a post-critical phenomenon ; in conjunction with 
head-symptoms and nerve-irritation. 

Conjunctivitis. — Not uncommon and not always indicative of deeper- 
seated lesion, as would appear. 

Ecchymosis of ocular conjunctiva: — Was noted in about 6 per cent, 
of fatal cases and may have overlooked sometimes ; in three examples 
selected, the site was right eyeball twice — once in a woman the upper 
half, occurring at seeming acme just before death ; at autopsy there 
being found small specks of cerebral haemorrhage in both hemispheres 
and many petechias in various parts of the body : in the other case 
the right eyelid also was ecchymosed, probably about similar date 
of invasion, and after death copious cerebral haemorrhage was seen 
chiefly at base on r, side. The third instance was that of a lad (hos- 
pital servant), ecchymosis occurring at acme of severe primary illness, 
followed by double pneumonia, pharyngitis and death in 6 days: autopsy 
not available. 

That this symptom is contingent, like most other localised attendants, 
on • impeded circulation, is shown by the following memoranda : — A 
young apothecary at my hospital caught relapsing fever, and at the first 
crisis both conjunctivae became blood-shot, purple spots also coming 
out on the skin ; with first and second relapses (unusually pronounced) 
the ecchymoses were not increased or repeated, but their absorption 
was gradual, traces remaining after a month. A native lad also infected 
in hospital, after the first fall showed large deep red patches in both 
eyes, which were not augmented at the severe relapse (with greater 
febrile changes than at invasion), and in course of absorption displayed 
a yellow tinge somewhat resembling jaundice. A woman was admitted 
at undetermined stage of fever in a very low condition and displaying 
ecchymosis on the right side only : she was removed before the end 
could be known. So far as appeared, the cause of these extravasations 
was not excessive vomiting, or like muscular effort. 

Corneal affections. — These being chronic and sequelar, were seldom 
seen in hospital : ulceration was noted in connection with irido-choroi- 
ditis at late post-febrile periods : and there is reason to suppose defec- 
tive corneal nutrition may have been not uncommon after this fever, in 
conjunction with general emaciation. 

Deep-seated inflammation of the Eyeball. — Post-febrile ophthalmia 
amongst survivors was probably not very rare ; near 5 per cent, of all 
cases may have been affected ; notes of several instances are before me, 
occurring at all periods of the epidemic and all in adult males. The 
right eye was commonly implicated, and in this series oftenest a few 
days after the invasion-attack ; occasionally after the first relapse : sub- 
jects usually, but not invariably, much debilitated. 

Selected instances of ophthalmitis were the following : — 

o 



194 SPIRILLUM FEVER. 

Case LVIII. — M., 25, suffered severely during invasion and relapse; 2 days 
after second crisis a bedsore threatened over the sacrum, next day he complained of 
much pain in the left eye, which had become affected with iritis ; under treatment 
mitigation ensued, but an exacerbation 5 days later, opacity of both cornea; (deepest 
on the left side) ensuing ; again slow amelioration interrupted by a brief second 
relapse ; ultimate result unknown : the spleen had been latterly much affected in 
this case. 

Case LIX. — M., 25, admitted at end of invasion, the blood-plasma then clear, 
fibrillation distinct, some free protoplasm present and numerous active spirilla : crisis 
very pronounced and rallying gradual : lo days after, diffused pain, redness, lachry- 
mation, intolerance of light in left eye, hazy cornea, pupil rather contracted, iris 
unchanged in aspect : mercury (with opium) was administered to salivation, and 
relief in 3 days ensued with seeming subsidence a week later; then the ophthalmia 
returned, and was similarly treated ; discharged convalescent 9 days later : quinine 
had been given during the interval. The ophthalmoscopic appearances were as 
follows — a shallow ulcer on the cornea, no deep-seated changes, and the dimness of 
vision complained of is accounted for by the artificially dilated state of the pupil. 

Case I,X. — M., 50, European, about 13 days after an abortive attack, the right 
eye became inflamed, vision being attended with distinctly granular cloudiness : the 
ophthalmoscope revealed only changes in the vitreous body, which vrry slowly 
cleared away : no other sign of relapse ; much general debility. The left eye was 
slightly implicated, in so far that vision was impaired by muscse: it had been 
habitually less strained than the right. 

9. Skin Eruptions — In the brown skin of Native patients, occupy- 
ing wards screened from sunlight, red spots were seldom prominent 
and, I doubt not, were often overlooked. At the better lighted G. T. 
Hospital, 1 found them quite at the beginning of the epidemic, and 
continuously afterwards, though not constantly. The commoner erup- 
tion consisted of minute pink (rose) spots, raised, readily effaced, and 
either fading forthwith, or changing into purplish, more persistent stains. 
Occasionally true petechise began at once : more rarely a diffused mot- 
tling was perceptible, and at times vibices. 

The pink spots were noted in 10 per cent, of later cases, and were 
possibly commoner earlier in the epidemic ; some groups' of subjects 
showed them oftener than others ; thus, famihes, patients from one 
house, or otherwise connected, as the 9 vernacular students who caught 
disease in hospital during 1877, of whom 5 displayed distinct spots. 
This form occurs in crops with the fever, and may continue to appear 
longer : it is equally frequent in first attacks and recurrences, being seen 
in both events, or in either alone ; it is rarely visible so soon as 2nd or 
3rd day (5 p. c. of cases), usually not till the acme of attack (12 p. c), 
or at the critical fall (20 per cent.) ; and i, 2 or 3 days after the crisis, 
it may persist, or even then first be found : the spots seem to come out 
at night, being generally noticed in the morning. Site — earliest or chief 
on the front (infra-clavicular region) and sides of the chest (below axilla, 
or at line of costal cartilage synarthrosis) ; then on front of abdomen, 
front and inner side of forearms and arms, less often on lower limbs ; 
on the back they were often present ; seldom above on the neck or face; 
exceptionally at root of neck, sides of sternum, wrists. On or near old 
sites fresh spots sometimes re-appeared. Aspect. — At the beginning 
some difference may be noted ; commonly they resembled small rose- 
tinted papules, quite effaced on pressure, without central dot, rounded, 
undefined ; quickly appearing and fading in 2 or 3 days ; or changmg 
to the next more persistent form. Frequently, the earliest aspect was 




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# *■ 



'\'ltJllJUM-yn<x,i.X.: 



The ERUPTION of SPIKILLUM FEVER 



COMPLICATIONS — ERUPTION. I95 

that of minute red blotches or stains, of breadth varying from a pin's 
head to a split pea, hardly raised, or if so flattened, shape circular or 
irregular, edges defined, not effaced on pressure ; apt to come out 
abruptly in clusters ; sometimes fading speedily, oftener turning dark 
purple, more visible, and lasting several days : the transition from these 
spots to the petechial was not rare. The total numbers varied from 
half-a-dozen, to two or three dozens or commonly more : the successive 
crops were few and irregular ; both forms may concur ; the more persis- 
tent lasting from one attack until or beyond the next recurrence, when 
new spots appear : I have detected the still fading maculae 3 weeks 
after their outbreak, and sometimes they became raised before disappear- 
ing. It happens the spots were not noted in infants ; at all other ages 
they were seen, and in both sexes : they were not attendant especially 
on cachexia, poverty, scurvy ; or on typhus-like attacks (altogether) or 
the ordinary mild or severe : nor were they connected with special 
clinical symptoms, or state of blood or urine : other haemorrhages might 
be present without these spots during life, or found after death. Mor- 
bid anatomy. — The pink papules disappear with disease : the purplish 
stains remain more or less apparent, and on division of the skin show a 
dark speck in the cutis, limited above by the pupillary layer, in other 
directions fading gradually, sometimes reaching the subjacent connec- 
tive tissue. Translucent sections display one or more foci of vascular 
congestion or stasis, with exuded blood or colouring matter around : 
the presence or character of any embolus was not ascertained in my 
interrupted examinations, yet it seemed clear that the changes were all 
of one kind, from the pink spot to purple blotch or true petechia. 
Diagnostic and prognostic import. — This eruption was first noted in con- 
nection with spirillum-fever during 1876-7, yet as it eventually proved 
not to be peculiar to the new disease, its significance becomes modified : 
in fatal cases of specific fever, the spots were only slightly more frequent 
than usual in those dying during invasion-attack, and less so in those 
dying later ; of 1 2 instances dying with first relapse, none showed them. 
Though not diagnostic, yet when occurring in fever possibly specific, 
they should engage attention : thus one of the vernacular students in 
1877 with pyrexia at first remittent, had the blood examined with nega- 
tive results ; but upon seeing a few purplish flattened spots, I tested the 
blood myself and found in it several active spirilla ; these were not 
again detected two days later, when the lad was at the point of death ; 
yet the diagnosis was valid, A hospital nurse caught the disease in the 
same ward, and at the same date as this student clerk ; she, too, had a.^ 
few spots, and also died : in neither of these cases was the temperature- 
chart characteristic of spirillum-fever as commonly conceived of 

Case LXI.— M., 22, vernacular student, on 7th day of invasion-attack showed 
some pink spots on the chest and forearms, some of which faded four days later and 
others were still visible after seven days as dark, very slight elevations : with the 
relapse fresh spots were detected in 2, 3 and 5 days, on chest, shoulders and arms, 
front and back ; the ones first noticed had now a measles-like aspect and purplish 
tint : the patient was not in a typhous state and rallied quickly : there was some 
diarrhoea afterwards, seemingly quite independent of the eruption. 

Case LXII. — M., 20, vernacular student, displayed a large ecchymosis on lower 
half of both eyeballs, suls-conjunctival, nearly symmetrical and simultaneously ap- 
pearing on day after crisis of first attack : no skin eruption and the ecchymosed blood 

o 2 



196 SPIRILLUM FEVER. 

was gradually absorbed in the course of twelve days, leaving a spurious jaundiced 
aspect : on 2nd day of the relapse a few pink spots made their appearance on the 
chest ; there was no return of the conjunctival haemorrhage : symptoms marked, but 
not typhus like or extremely severe. I have seen another instance of ocular ecchy- 
mosis with spots on the trunk simultaneously. 

Case LXIII. — M., passed through a marked first attack, and on 2nd day after 
crisis a crop of pink spots was seen on the chest, which disappeared on pressure ; 
next day, a few others some of which were of brief duration (3 days), but others on 
the shoulders and back became persistent, being slightly raised, of purplish hue, and 
lasting till the relapse and ensuing fall : during this recurrent attack fresh spots were 
not seen : fever of low type. 

Case LXIV. — M., 33, on 8th day of invasion -attack there were a few small pink 
spots on the chest and abdomen, which increased in depth of tint next day and were 
not wholly effaced on pressure ; they had not the dark aspect of confirmed petechise, 
yet some of them lasted for upwards of three weeks, the patient meanwhile under- 
going an attack of suppurating parotitis, which supervened 8 days after the crisis (i.e. 
about the time of relapse), and on that date there was an outbreak of fresh spots. A 
weak subject, whose wife had the fever, and whose child died of it. 

Case LXV. — A man, 35, showed a few pink spots on the chest at close of first 
attack, not effaced on pressure and gradually fading in the course of four or five 
days : 6 days after the first crisis, there was headache and sweating with a very 
slight rise of temperature (99° "2) about then and a distinct outbreak of pink spots on 
the front of chest and abdomen, which did not fade for three days. 

Case LXVI. — Eruption in a case of Typhus icterodes. — M., 35, Muss, weaver, 
from Lucknow, in Bombay a fortnight, admitted from a factory sending other cases 
to hospital : Jan. 1880. Fever of 7 days' duration ; t. 102° •2, p. 128, deep jaundice and 
much debility— numerous red spots in 1 ft infra-clavicular fossa, level, purplish, size 
and form irregular (some being as large as a pea), clustered and ineffaceable on 
pressure : a few on the back and arms : on the back also some large hyperasmic 
patches : no mosquito bites : many spirilla in the blood. Acme and crisis within 
the next 24 hours ; with the fall the skin becoming rather pallid, the blotches were 
more distinct, some now resembling true petechite ; a few fresh spots on the chest : 
red patches on the back gone. With a slight rebound was much depression, with 
hiccup (? petechise in stomach), and also a copious eruption of new purplish spots, 
varied, papular: next day decline of temp., some more fresh spots ; there was sore 
throat with vascularity, and apparently purple discolorations on the fauces and tonsils. 
In the ensuing apyretic interval, all the eruptions began to fade, and after 3 days 
the older purple blotches had nearly disappeared (to my surprise), the later pink 
spots now become purplish and puffed (not inflamed) as if from irritation of the ex- 
travasated blood, or some new local growth : axillary glands not enlarged or tender. 
The man rallied quickly ; a brief intercalated paroxysm now occurred : and probably 
a few fresh spots came out : after a second apyretic interval another pronounced 
relapse took place, at the crisis of which, in the place of ordinary eruption, I noted 
some minute specks of cutaneous haemorrhage in the upper intercostal spaces close to 
the sternum, where the intercostal arteries terminated by dividing and then come 
forward : the patient rallied remarkably, and 14 days after his admission the eruptions 
had quite gone. His son occupied the next bed, and with his specific attack, also 
showed the eruption, but without jaundice and typhus-aspect. Fide Chart No 10, 
Plate II., and the coloured illustration. 

It appears to me that these spots partake of a common origin and 
character : the lighter-tinted papular form being due to slight or 
temporary blood-stasis in the derma, whilst the less transient is a real 
blood-stain, due to actual extravasation ; and obviously an inter-transi- 
tion is possible here, as well as termination in true petechise. In genera 
aspect, their resemblance is mostly to the eruption of typJms exaiithe 
7)taticus ; but otherwise to that of typhus abdomhialis, as regards scanty 
numbers and advent in successive crops : so that, supposing the ordinary 
distinction of English tyjjhus and enteric eruptions to be insisted on (a 



COMPLICATIONS — PETECHIA. 197 

point to myself seeming hardly tenable), then these spots would be re- 
garded as partaking of a mixed character. 

Having detected a precisely similar eruption in non-specific fever of 
the remittent (typho-remittent) character, and also in pneumonic and 
hectic (?), at the same epoch in Bombay, I consider the pathological 
signifi'^ance of this clinical sign may be more extensive than is yet re- 
cognised. 

It is necessary to state that the appearances above described may be 
closely simulated by the bites of the common small mosquito, or, less 
palpably, of the ordinary flea : thus, the mosquito-bite may not show a 
central prick, and in vascular cutis of the face and thinner cutis at the 
wrist, it may be attended with defined blood-stain or extravasation : its 
duration, too, varies like that of the spots, the nocturnal advent of which 
further favoured this idea of their occasional origin from the insect pest 
of some wards. 

On the other hand, these incidental punctures are more regular in 
form and size, found only upon exposed parts, are very seldom clustered ; 
and do not last a week or more, or ever change into purple stains, or 
true petechiae. In a strict sense, the production of all such spots is re- 
ferable to a common origin, namely injury or rupture of minute blood- 
vessels in the cutis vera or deeper down. I found, on some trials, that 
application of the cupping glass did not bring out the spots, but rather 
rendered them less distinct, owing to the local hyperaemia resulting 
from diminished air-pressure. 

ID. Fetechice. — Spots manifestly hsemorrhagic and indelible from the 
first, were less usual than the above ; but into such definite form, the 
pink blotches sometimes passed before fading. Therefore, it would 
appear there are several grades of sangumeous effusion regulated by the 
amount or rapidity of extravasation, and possibly by the character of the 
exudation. According to my experience the more evident petechise 
were to be found in remittent and other ill-defined fevers, at the late 
epoch ; and hence they had no real diagnostic value : their site is al- 
ways alike, whenever found. Perhaps they were most abundant, how- 
ever, in the worst form of spirillum fever, or that attended with deep 
jaundice and a typhus aspect. Diagnosis — black pigment-spots in 
native skins, may closely simulate petechise. 

Case LXVII. — K. S. , 24, Muss, weaver, admitted on 8th day of invasion, dying 
next day (? at acme), t. lo5°-8, the blood containing many large spirilla and fat- 
granule cells, coagulating imperfectly, and being of thin, brown aspect. Besides a few 
minute vesicles on front of chest, there were many petechiae about the elbows, in 
axillae, on front of shoulders and on the back, with some lai-ger purple stains on front 
of abdomen and chest ; these were true haemorrhages, some being bright red, others 
becoming purple, and acquiring a tinted halo: in the axillae were several dozens of them. 
There were some ecchymoses in the injected conjunctivas: pupils decidedly contracted 
and equal : internal haemorrhages were found after death, the man dying of cerebral 
effusion and enteritis. In another case dying of pneumonia after the invasion, petechia 
appeared on the reputed 7th day of disease on the chest and back, arms, and lower 
limbs (also it is said on the face); those I saw beneath the clavicle were very dark, 
numerous, and clustered, yet they are reported as disappearing 5 days later or just 
before death : patient a Hindoo labourer, ast. 30 : date 2 July, 1877. Such brief 
duration of spots decidedly resembling blood-effusion, was not rare : it is striking. 

II. Rashes. — Purplish mottling of the skin, in patches, was very 



198 SPIRILLUM FEVER. 

rarely noticed ; obviously, it might have been overlooked in the dark 
skins of native patients, yet it has been distinctly seen, usually with the 
rose-tinted or purplish eruption {vide Case LIV.) ; and I perceived 
some hypersemic patches in my own skin at first attack. On the appli- 
cation of a cupping-glass, such rashes were not intensified. 

Vesicles, pustules and boils, were occasional attendants and early 
sequels of specific pyrexia. Once I noted at the onset of first relapse 
(spirilla in the blood) a large darkish vesicle on the thigh, looking like 
' Charbon,' the liquid contents of which did not coagulate spontaneously ; 
large granule-cells were present, some filled with actively moving 
granules, also moving free granules which I compared to micrococci ; no 
spirillum here. Next day a slough had formed, the pus around which 
contained, beside pus-corpuscles, an immense number of micrococci, 
identical with those in the swarm-cells : date May, 1877. The patient 
had epistaxis at the time, and thrice afterwards, with active delirium at 
crisis : the fever was of low type, eyes injected and jaundice, with en- 
larged spleen ; convalescence tolerably prompt. Commonly pustules 
appear later : M., 35, with low fever, shortly after a brief relapse, a pus- 
tular eruption on the left knee, and earache : boils were generally 
sequelar. 

T2. Desquamation of the Cutic/e. ~-This was quite unusual, except in 
the form of minute branny scales following the drying up of sudamina : 
after even profuse sweating and maceration of the epidermis, apparent 
exfoliation did not take place. Once it was noted on the limbs after 
invasion of low type (lysis) with oedema and a few pink spots, hypo- 
gastric tenderness, diarrhoea ; urine retained, sp. gr. loio, pale, clouded, 
a little albumen : there were signs of a latent relapse at the time. It 
was seen on the neck of a man on last day of relapse, before critical 
sweats : and has been noticed on the corpse. Exfoliating cuticle was 
then in comparatively small flakes. For instances of desquamation at 
crisis with little or no sweating (perhaps in consequence thereof) see 
above Cases XVIII. and XXI. 

13. Odotir emitted from the Skin. — In several cases, both surviving 
and fatal, from the body of patients, a sour, musty, or offensive smell 
was given off, especially about the time of critical sweats : sometimes 
this was so evident as to be complained of by the sick man himself, and 
in the instances I met with the skin was not in a particularly foul state : 
it is not the odour of dysentery or colliquative diarrhoea. 

14. Spontaneous Gangrene. — The lividity, coldness and shrinking of 
nose, ears and extremities of limbs, however noticeable at acme and 
fall of fever, did not persist and were not followed by local gangrene. 

At height of the epidemic, I once saw gangrene of the cheek in an 
adult male, contemporary with the presence of granule-cells in the blood 
large enough to block the skin capillaries : further particulars of this 
case (which much impressed me at the time of its occurrence) have been 
mislaid. 

15. Bed-sores. — Sloughing from pressure. The occurrence was rare, 
although many patients had been much reduced by want : the following 
instances show the varying conditions under which it was seen, primary 



COMPLICATIONS — BRONCHITIS. 199 

fever being amongst these. The local effect of involuntary faecal and 
urinary evacuation did not seem to be concerned here. 

M., 45, butler, habits possibly not temperate, and affected with elephantiasis of r. 
leg : exhibited pronounced symptoms of spirillar infection (first attack), and on 
reputed 8th day, or acme, redness appeared on the back, which with continuation 
of fever (now attending pneumonia) ended in bed-sores, the scrotum also becoming 
excoriated; death on second day after apparent critical blood-change. This early 
supervention of decubitus is noteworthy. 

M., 25, weaver, weak subject ; at end of pronounced first relapse was much reduced, 
and showed diffused inflammation over lower end of sacrum and coccyx ; which, how- 
ever, under his rallying did not pass into wide sloughing : recovery after a second 
relapse. 

M., 50, destitute, 30 days after end of specific infection attended with moderate 
pyrexia, but abundant visible blood-contamination, acquired bed-sores and lingered 
in a feeble state for four weeks longer. 

Complications affecting the Respiratory Organs. — The principal and 
most frequent of lung-changes found after death being that of pneu- 
monitis (present in nearly ^ of autopsies), in the remainder of cases the 
lungs were in an opposite condition of pallor and collapse, or only con- 
gested, or of quasi-normal aspect. Presuming these varied conditions, 
after excluding degrees of pneumonia, to represent the state of the 
organs amongst surviving fever-patients, it may be said that the common 
symptoms of hurried breathing and slight cough, with scanty mucoid 
sputa, do not imply more than slight or non-persistent lung-changes ; 
whilst severer dyspncea, cough, rales and hardly altered percussion-note, 
attend the state terminating in paleness and inflation or collapse. Con- 
gestion of the organs, diffused, lobular or hypostatic, did not give rise 
to special symptoms in addition to those already well known, but it 
often happened that owing to extreme feebleness or depression of the 
patients, close physical examination was impracticable. I am unable, 
also, to add many clinical details of the rarer lung-lesions mentioned in 
the Chapter on Morbid Anatomy (some of which may have supervened 
shortly before death) ; and it must suffice to invite attention to these 
several lung-complications, as affecting both diagnosis and prognosis. 

16. Laryngitis. — Two or three instances were met with of sudden 
implication of the larynx, resembling acute cedema or transient inflam- 
mation : the symptoms were of mild character, and not persistent. 
Implication of this part in extension of pharyngitis, I do not recollect 
seeing. 

1 7. Bronchitis as a separate affection, seemed to be practically un- 
known at necropsy : and however frequent it was as an attendant upon 
the pneumonia usually causing death, amongst survivors bronchitis of 
definite presence was by no means common. When occurring, its 
tendency was obviously towards deeper lesion ; and I regard it as pro- 
bable, that most of the examples of bronchitis as a complication of 
spirillum fever, were instances of mild catarrhal pneumonia ; this opinion 
being founded on the scrutiny of cases showing non-specific pyrexia 
either continuous with the spirillar attack, or appearing as secondary 
fever after crisis. The fatality of pneumonia in this fever would appear 
unusually high, unless it be supposed that some of its milder forms 
were so blended with bronchial inflammation as to become liable to 



200 SPIRILLUM FEVER. 

oversight or misinterpretation ; just as is known to happen in other 
fevers, and also independently of specific infection. 

Acute bronchitis seen during spirillum fever may be regarded as a 
quasi-exaggeration of the lung congestion invariably present in some 
degree ; and where it supervenes after the crisis with secondary pyrexia, 
there will be almost always found present other local derangements (as 
of liver, spleen, bowels), with a tendency to depression, or the typhoid 
state, or delirium. 

Instances of this kind were not uncommon, especially amongst the 
Mussulmans from N. India : they were seen in adults and children 
of both sexes ; and though rather more frequent after primary invasion- 
attack, yet also happened after the first relapse ; it being noteworthy that 
the secondary fever (judged to be non-specific) with its lung and other 
complications, sometimes appeared about the time of, and as it were in 
the place of, a simple recurrent attack. The severity of the phenomena 
varied, but not seldom it was obvious that if a little prompter in oc- 
currence {i.e. nearer the critical depression going before), or more pro- 
nounced in degree, the complication might have proved fatal ; the main 
determining consideration, in my mind, here referring to the presence 
or extent of actual pneumonic lesion. 

The relationship of pronounced bronchitis (so-called) to pneumonia, 
and the great frequency of these complications in severe attacks, were 
evident amongst a group of 15 hospital servants infected in their wards : 
6 of 9 survivors presenting them in marked degree, and 3 of the 6 
deaths being mainly attributed to lung inflammation. 

Such milder degrees of bronchial congestion and inflammation as 
promptly subside with specific fever, or if lingering do not lead to mani- 
fest perturbation of the system, were the most frequent of all com- 
plications : they shade off" towards the above-named severer forms, or, 
on the other hand, to the ' cough ' already alluded to as a nearly in- 
variable symptom. 

In the last series of cases analysed, decided bronchial congestion 
during the invasion- attack, was noted towards its close in 54 p. c, at 
the acme in 66 p. c, and at the crisis in 35 p. c. of instances ; these ratios 
indicating a progress towards maximum with the final perturbation, 
when, there is reason to believe, pneumonia eventually fatal often was 
initiated. Amongst all casualties, the tendency of bronchitis was to 
augment till the crisis or end of attack. 

During beginning of the first apyretic interval this system persisted 
in 20 p. c. of cases, entirely subsiding, however, by the 4th or 5th day : 
it occasionally first appears at this stage on 2nd, 3rd, ist, or 5th day, 
and at all these dates pneumonia was known to begin, when the lung 
complication became severe. I also noted bronchitis with some pyrexia, 
about the date of a regular recurrent attack. 

With first relapse the symptom appeared or re-appeared, chiefly 
towards the close in 17 p. c. of cases, at acme in 24 p. c. and at 
fall in 22 p. c. : its diminished frequency at the recurrence being in 
correspondence with less evident blood-contamination and briefer 
pyrexia ; then, too, the severer pneumonic lesion becoming compara- 
tively uncommon. In casualties, bronchitis was rare, except along with 
pneumonia. 



COMPLICATIONS — PNEUMONIA. 201 

During the second apyretic interval it was noted in only 9 p. c. of 
cases, being early, mild and brief. 

It did not appear to me that in the uniform, tropical climate of 
insular Bombay, season of the year exerted any decided influence on 
the prevalence of the lung-complications ; the majority of cases being 
seen between April and September (when famine-fever attained its 
maximum), and not during the cooler winter season. 

18. PneumoTiia. — This compUcation was both frequent and serious ; 
and its forms and degrees were as varied here, as under combination 
with remittent or other fevers. 

The notes of 21 autopsies show consolidation of an entire lung 4 
times (3 on right side), there being also engorgement of the opposite 
organ, and marks of pleurisy : the lower lobes only were solidified 8 
times, viz. 4 on both sides and 4 on one side (the right and left equally 
often) : the upper and middle lobes alone were condensed 5 times, and 
in 4 instances there was disseminated induration in one or both lungs, 
partially or throughout. Pleurisy co-existed, in all, 13 times. - _ 

At decease the inflammation had not passed the first stage 3 times, had 
reached the second stage 12 times, and the third 5 times ; whilst in i, 
consolidation seemed to be chiefly from lobular haemorrhage. 

In 4 deaths at close of invasion-attack, the pneumonia engaged a 
whole lung or the lower lobes of one or both lungs, and it had already 
attained the second stage: once the form was that of disseminated patches 
of induration, and twice, at least, there was some pleurisy. As in 2 other 
instances of death on second and third day after the crisis, there was 
similar evidence of advanced disease, it seems clear that pneumonia 
may come on very early in a first spirillar attack, and its own symptom- 
atic fever be lost in the specific pyrexia. 

Most deaths from this complication took place within a week or ten 
days after the first crisis, a non-febrile interval, more or less distinct, 
being interposed prior to secondary fever ; and between the two groups 
of completely blended pyrexias and the clearly sequelar pneumonic, there 
were seen gradations of concurrent fever not easy to interpret without 
repeated scrutiny of the blood. In 3 deaths from 5th to 7th day, the 
upper lobes of the lung were inflamed ; in 3 others dying from 9th to 
loth day, the lower lobes or whole lung ; and I mention these data, 
because it was possible the later difference might be connected with 
latent spirillar infection. In another instance, pneumonia commencing 
at first interval became continuous or confounded, with the specific 
relapse ; and such intermingling (here carefully unravelled) might be 
regarded as indicative of a further series of cases wherein the whole 
apyretic interval became occupied with extraneous fever, and so the 
spirillar pyrexia entirely hidden ; several examples of such incidentally 
' continued ' fever were met with, in both living and dying. 

During the second apyretic interval, pneumonia again appeared, 
though less often, the milder relapse probably less predisposing to it ; 
there was one death on the fourth day (upper and middle lobes in- 
volved of left lung), and one on the fifteenth (disseminated patches of 
induration in right lung). 

Pneumonia might set in 3 or 4 weeks, or longer, after the close of 



202 SPIRILLUM FEVER. 

specific pyrexia, primary or secondary ; it had then no special cha- 
racters, engaging either whole lung or both lower lobes. 

This autopsic series and a few other fatal examples, together furnish 
27 instances of pneumonia in 97 casualties, or 3 7 "3 per cent, which may 
be rather under the truth, as the pneumonic complication is apt to be 
overlooked ; this proportion exceeds, however, the scanty ratio of 
pneumonia amongst survivors, for death seems to be the ordinary ter- 
mination of undoubted lung-lesion of this kind. My notes contain few 
instances of recovery after decided pneumonic inflammation, at any 
stage of spirillum fever ; whilst there are several of recovery after marked 
bronchitis, coincident with ordinary pneumonic dates of end of invasion 
and early post-crisis period : as before intimated, the comparison here 
is strictly between fully-developed and quasi-latent pneumonia, results 
depending partly on the amount of parenchymatous lung-lesion involved. 

As to the nature of the secondary pneumonia, it is open to question 
if it were always the same ; and a correct discrimination here, may be 
the first step to preciser knowledge. 

From the evident connection of this complication with the close of 
the first and severest attack of spirillum fever, it might well be sup- 
posed that the contemporary overloading of the blood with leucocytes 
and granule-cells was some way concerned in its production : yet I have 
shown that in several typical instances of death at close of invasion, 
the lungs were pallid and sometimes partly collapsed ; and, besides, 
pneumonia may come on several days after the fall when the blood has 
regained its normal aspect. When, however, lobular collapse takes 
place about this time, inflammation may promptly supervene in these 
shrunken parts and thus give rise to disseminated indurations. 

According to current pathology, such partial collapse of lung tissue 
is apt to follow on inflammation of the finer bronchial tubes ; and I 
have before stated that bronchitis is one of the commonest attendants on 
spirillum fever. Two autopsies have been described where the base or 
the entire lung was permeated by fine frothy serum, death happening 
at invasion-fall or end of relapse ; here, too, localised collapse might be 
looked for. That acute capillary bronchitis also terminates in lung 
solidification (here included under the head of Pneumonia) was dis- 
tinctly proved by another case dying on ninth day after crisis, with the 
back part only of left upper lobe in a state of splenisation, the rest of 
the lungs displaying the signs of acute bronchial catarrh. 

For some of the examples of pneumonia seated in the lower lobes 
of one or, especially, of both lungs, the term hypostatic might be re- 
garded as correct. 

There were two or three instances of highly localised indurations of 
tissue at the surface of the lungs, in different parts, when pleurisy also 
was present ; and these I should regard as examples of pyaemic, or 
toxsemic, pneumonia. The concurrence of bubonic and diphtheritic 
inflammation would also be evidence of blood-contamination. 

There still remains to consider the cases of croupous or lobar 
pneumonia, and as possible explanation of them, individual sus- 
ceptibility, malarious influence, incidental exposure to cold or some 
unknown blood-contamination, may be named. Reference should 
here be made to the Chapter on Morbid Anatomy. 



COMPLICATIONS — PNEUMONIA. 20,^ 

The mortality must in general be considered high, and the prognosis 
as bad. 

Nothing peculiar appears in the clinical characters of specific 
pyrexia attended with, or followed by inflammation of the lung ; an un- 
selected series of 12 fatal examples giving 8| days as the mean duration 
of the attack (primary) ; the last-noted temperature and pulse as t. 
1 04° "5, and p. 128, or only a little in excess of the means in survivors ; 
the critical fall when seen was direct in 8, lytic in 3, and once only 
partially witnessed, mean minima t. 96° "6, and p. 95, which is higher 
than the general mean, and therefore a quick pulse at the fall should 
engage particular attention. There was a prompt rebound of tem- 
perature 7 times, with early initiation of lung symptoms ; 3 times this 
rise was deferred, and in 2 cases there was no rallying after crisis, 
although then the lungs were much inflamed — an important datum. 
Death partly or wholly from pneumonia occurred on any day after the 
crisis from the first to the thirty-fourth ; mean date ten days. The 
apparent mean duration of symptoms was for death at the first or second 
stages, about 4 days ; and at the third stage, 9 days. 

According as the pneumonic fever is present alone or blended with 
the specific, so will its own features be more or less apparent ; in it gene- 
rally the mean temperature was lower and pulse slower (though firmer) ; 
the headache, thirst, and aching pains decidedly less pronounced, and 
the hepatic, gastric, or splenic implication altogether wanting. On the 
other hand, the frequent cough with viscid, bloody sputa, pain in the 
side and marked dyspnoea, together with the usual physical signs of in- 
flammation of lung or pleura, belong solely to this complication. As 
to the varying facility with which the local disease may be made out, I 
need only remark that minor degrees of catarrhal, pyaemic and hy- 
postatic pneumonia were apt to be overlooked under the ordinary con- 
ditions of enquiry at Bombay, which seldom permitted thorough clinical 
scrutiny of the chest, day by day ; this experience is not peculiar. 
Valuable as a thorough investigation might prove, the observations it 
was possible to make did not reveal any novel positive data, as to the 
nature and causes of inflammatory lung-implication. 

In the series analysed, there were no cases of infants and propor- 
tionately few of women. Practically, nothing could be learnt of pre- 
existing states of the lung in most cases ; but old bronchitis, asthma and 
phthisis were sometimes known to be present, without pneumonia 
supervening with the specific pyrexia. 

Influence of Season. — During the years under review pneumonia, 
in general, was commonest at the close of the rains and in the 
cold season ; in connection with spirillum fever, however, such distri- 
bution was not so apparent : thus in the larger J. J. H. series, of 29 
fever-deaths from March to May (hot season) there were 8 with 
pneumonia ; of 25 from June to August (wet season) there were 7 ; of 
22 from September to November (malarious season) there were 4 ; and 
of 6 from December to February (cold season) there were 3. In 15 
other deaths there were 4 with lung-inflammation, of which 2 occurred 
in the hot season ; and as characteristic examples of all forms of pneu- 
monia were seen throughout the year, I infer that this complication was 
not essentially connected with atmospheric states. 



204 SPIRILLUiM FEVER. 

More importance would seem to attach to the influence of specific 
contamination, aided by privation, checked excreta, mental anxiety and 
prior malarious cachexia, upon the blood and system in general of the 
subjects implicated ; which of these co-agencies were most effective, 
the data do not enable me to say. 

The clinical cases supporting the above remarks also show, that 
whilst the physical signs of pneumonia may be tolerably constant, the 
accompanying pyrexia was highly variable. Perfect lung-consolidation 
not being found prior to the critical fall of invasion, two instances were met 
with of death at this time with confirmed double pneumonia ; unfortu- 
nately they were not seen till 8th day of illness, and hence I am able 
to state only that the crisis was not excessive or peculiar; death took 
place one or two days later. One of these cases is copied here : — 

Case LXVIII. — M., 40, m. after admission t. i03°-2, p. no, breathing hurried, 
countenance dull, some jaundice, tongue and skin dry, headache, thirst, pains, con- 
stipation for 8 days, abdomen tender and tympanitic ; chest reported normal to aus- 
cultation and percussion ; the blood full of spirilla. Defervescence now began 
without sweats, and continued by lysis, the min. being reached in 2^ days, t. 97° '2, 
p. 88 ; purple spots appeared, hiccup, slight cough, pulse extremely feeble, respira- 
tions 24 per minute, some sputum tinged with blood, delirium, coldness of the limbs 
and death in the aspect of collapse 36 hours later. The whole of the lower lobe of the 
r. lung was consolidated and softened ; lower lobe of 1. lung deeply engorged ; paren- 
chymatous inflammation of the liver, spleen large and soft, kidnies pale and soft, 
vascular patches in the intestinal mucous membrane : so far as known here, pneu- 
monia had come on during the gradual defervescence, whilst the t. was falling, and 
the instance may further be regarded as pointing to the complications liable during 
lysis of spirillum fever. 

Two other selected instances in youths of 16 and 20, show pneu- 
monia supervening immediately after crisis, concurrently with smart re- 
bound of t. : in one case death happened 9 days afterwards, the fever 
becoming remittent, pulse variable, typhoid symptoms before the close: 
the r. lung was emphysematous, dry and bloodless; the left inflamed 
throughout and its lower lobe suppurating: changes elsewhere not strik- 
ing. The other instance is reproduced : — 

Case LXIX. — M. , 20, emaciated, gave a history of fever, but none seen for 
10 days after admission, when a smart attack set in suddenly, and lasted 3 days ; 
spirillum present, and many usual symptoms; at the crisis a descent of 10^ "5, p. sank 
to 80 from 144 ; drowsiness and some delirium at the end ; an immediate rebound 
took place and on second day t. io5°"2, p. 128, no delirium but great depression, no 
cough seen or heard, no expectoration, yet dulness at 1. apex, in front with tubular 
breathing on third day ; increasing weakness and death two days later, without per- 
manent defervescence. At autopsy — r. lung healthy, upper and part of lower lobe of 
1. lung in first stage of inflammation, with reddish serum in the pleura ; splenic in- 
farcts and old colitis. Chart 26, Plate VI. This was an example of pneumonia 
directly following spirillar infection, and the chart shows how closely pneumonic fever 
may resemble pyrexia of ' rebound.' 

The following case shows more deferred lung-disease, and especially 
the difficulty there may be of correct diagnosis, when pneumonic and 
spirillar fever become blended : — 

Case LXX. — M., 22, scorbutic, admitted on 4th day of pronounced invasion, 
with most of the usual signs of infection : pertutbatio critica and crisis with relief ; 
slight cough only and no sputum : mild secondary fever ensued with pains in the 



COMPLICATIONS— PLEURISY. 205 

joints, which subsided in two days, and my note was that the patient now looks con- 
valescent for the first time ; fever, however, promptly returned and it persisted with- 
out evident complication for three days, the man rapidly becoming prostrated : then 
the blood on close scrutiny by the Albrecht process displayed a very few spirilla, 
there was slight mitigation of the symptoms, with no alteration of temperature, and 
some consolidation of the r. lung above was noted : pyrexia continuing, the typhoid 
state supervened, with splenic and hepatic fulness and tenderness, delirium, loose- 
ness of the bowels, a dicrotic and very feeble pulse, dyspnoea at the last. After 
death— apex of r. lung consolidated, on its surface some marks of pleurisy, and com- 
mencing gangrene ; also were seen converging white lines, as of lymphatics contain- 
ing fatty matter or pus, and within the lung-parenchyma the larger vessels around 
were filled with pale clots : liver enlarged, with pale patches in it ; mucous mem- 
brane at mid-region of stomach highly injected ; spleen little changed ; kidnies much 
congested. In this instance, also, the pneumonia seemed to be of blood-origin ; 
source of poisoning unknown. Chart 24, Plate VI. : date of relapse indicated only 
by blood-spirillum appearing. 

Pneumonia causing death at later periods of the fever was compara- 
tively rare : an instance was the following : — 

Case LXXL — M., 30, scorbutic subject, gave a history of first attack, the end of 
a relapse being witnessed in hospital : then ensued a series of mild daily febrile per- 
turbations which continued for a fortnight, the t. never rising above 101°, but p. 
seldom below 100; finally a sudden rise to 103°, p. 118, and death next day, pro- 
bably from syncope. During this period, the blood was frequently examined with 
negative results ; no definite complication was noted by the medical officer in charge, 
debility being the main symptom all along. At the autopsy— disseminated lobular 
pneumonia at advanced stage in r. lung ; left lung healthy ; clots in the heart, liver 
very large (fatty?), and so the spleen (softened), kidnies healthy-looking; subcu- 
taneous effusion of blood and serum in the lower limbs. This was another example 
of the modified lung-inflammation found after spirillar infection. 

Respecting the cases recovering from pneumonia after fever, the 
amount of lung-consolidation seems to have been always slight, although 
fever might be high ; bronchitis had usually preceded and other com- 
plications were often present, the pneumonic not having the predomi- 
nance noted in fatal cases. Excluding the more probable examples of 
blood-deterioration, it might, however, be said that in all essential par- 
ticulars, except that of intensity, no difference obtained between cases 
surviving and the dying. The usual symptoms were not noted, and 
the whole tendency of evidence was to show that lung-solidification might 
certainly exist without its presence being suspected. 

There are no other data bearing on recurrence of pneumonia, but it 
is not improbable the examples seen of lung inflammation supervening 
a fortnight, or longer, after specific crisis, were connected with the infec- 
tion through dormant lesion earlier incurred ; and in some subjects, it 
is likely that a predisposition to acute pneumonia was then established ; 
for best on such hypotheses, can be understood the sudden recurrence 
of severe local symptoms after a long interval of quasi-convalescence. 

19. Pleurisy. — Not seldom seen in connection with pneumonia, this 
complication was sometimes the more striking indication of blood- 
poisoning ; as appears in the following case : — 

Case LXXTI. — F., 12, admitted with high fever and dysenteric symptoms said 
to be of several days' standing : the blood contained spirilla ; there was no couo-h, 
breathing quickened, frequent muco-sanguineous stools with tenesmus, lumbrici 



206 SPIRILLUM FEVER. 

passed ; after a final marked paroxysm the fever declined, becoming mild and irre- 
gular, purging continued, much emaciation ensuing and death 8 days later. At 
autopsy — mucous membrane of large intestine studded throughout with round, raised 
ulcers, largest in caecum and rectum ; lungs non-adherent, mostly crepitant, the right 
pleura widely inflamed including its diaphragmatic layer, with streaked vascular 
lymph on the parietes, contents turbid, flaky serum ; at base of r. lung was some con- 
solidation apparently due to fibrinous infiltration in the form of nodules, one of which 
was as large as a nut ; the heart, liver, spleen and kidnies seemed healthy ; there was 
some reddish serum at base of brain. 

Pleuritis also occurred in conjunction with febrile turgescence of liver 
or spleen, as indicated in another case : — 

Case LXXIII. — M., 20, admitted on 7th day of invasion, symptoms pronounced; 
after marked critical perturbation and defervescence, there ensued secondary fever, 
which from the 3rd day assumed the form of daily remittent paroxysms till decline in 
8 days more, max. t. 103°, p. 120; on admission I noted unusual quickness of the 
breathing, which at acme was 48 per minute ; no dullness of chest, some dry cough, 
as usual ; heart's systole loud, much abdominal fulness and tenderness, right rectus 
abdom. muscle tense, tongue red, shrunk and dry ; much distress at the acme, with 
delirium, involuntary evacuation of faeces, jaundice, the urine free from albumen : 
after crisis depression and continuance of splenic pain especially, quick breathing, 
dry cough and on 4th day acute pain in left side of chest, where a loud friction sound 
was audible : hepatic tenderness diminished ; the man was now reduced in flesh, and 
sleepless from the pain and cough, but did not become worse ; pain in the 1. shoulder 
followed, most at night, the spleen had gone down, urine continued free from albu- 
men ; with decline of fever convalescence after 3 weeks. Here I associated the pleurisy 
with peripheral splenitis. 

20. Astlima. — That amongst other chest complications, pre-existing 
asthma may become greatly, perhaps especially, aggravated during an 
attack of relapsing fever, was shown by the following case : — 

Case LXXIV. — M., 40, spare, admitted at close of a febrile attack attended 
with bronchitis (seemingly chronic) ; no blood examination : soon rallying, he re- 
mained well for 10 days, when fever returned with renewal of the chest symptoms, 
the dyspnoea becoming urgent ; t. daily reached 104°, p. mounted to 150, and soon 
after this the blood-spirillum at first not seen (? overlooked) became visible : judging 
that the respiratory troubles were disproportionate to existing signs and other symp- 
toms, enquiry was made and it was learnt that the man had been subject to asthma 
for 5 years. The ensuing interval was now occupied by febrile paroxysms (non- 
specific) and without subsiding the dyspnoea became lessened : after 8 days spirillar 
pyrexia recurred, lasting 5 days and ending abruptly ; a brief yet smart rebound fol- 
lowed (anal abscess now), after which the normal level : during this relapse the man's 
sufferings were very great ; with the signs of chronic bronchitis, there was no dullness 
of the chest and rallying was prompt on cessation of fever : mild dysentery alone 
checked an almost unlooked-for convalescence. Without the aid of the microscope 
this long attack would, I doubt not, have been regarded as one of remittent fever 
with bronchitis : see Chart 12, Plate V. It is probable contagion occurred in 
hospital. 

The dyspnoea at acme of uncomplicated spirillum fever often being 
remarkable, in certain cases it may simulate asthma ; then, at least, 
trenching on the narrow limit between functional and lesional chest 
derangement. 

Case LXXV. — M., 37, hospital servant, caught fever while on duty in a medical 
ward ; the attack lasted 7 days, being pronounced, and declining slowly, some irre- 
gular perturbations of t. followed, but no distinct relapse ; the pulse, not unusually 
frequent at first, at acme and fall much quickened, together with the chest symptoms ; 
and it afterwards remained irritable. Until the 6th and last day of fever, there was 



COMPLICATIONS — PHTHISIS. 207 

no complaint of breathing; previous e. t. 104° •6, p. 100, wet sheet packing applied: 
this m. t. I02°'6, p. 120, full, bowels relaxed, no sleep, cough and oppression on the 
chart have supervened, sputum scanty ; e. t. io^°-8, p. 128, some sweats during day, 
less headache, the sense of suffocation remains : 7th day, m. t. declined to 101°, 
p. 120, soft, is not able to lie down from dyspnoea, chest resonant, respiratory sounds 
distinct, heart sounds feeble only, eyes heavy and suffused, general aching pains, sl<in 
moist, tongue dryish and brown ; some oedema of the insteps : bowels relaxed : e. t. 
9S°'4, p. 116, skin clammy, the dyspnoea not less: 8th day, m. t. 97°"4, p. 140, 
small and soft, he cannot lie down, no cough or expectoration ; left side of chest pos- 
teriorly is slightly dull on percussion, breathing there tubular, voice resonant, moist 
rales heard around ; he vomits upon eating (hiccup next day) ; urine high-coloured, 
acid, 1013, contains |- vol. of albumen; 3 stools semi-consistent: e. t. 96°, p. 112, 
better developed (lowest critical fall oft.), the difficulty of breathing is less ; remedies 
had been actively employed. On the following day, m. t. 97° '2, p. 96, chest symp- 
toms subsiding, tongue dry, hiccup; e. t. 97° "6, p. 100, hiccup ceased, he can lie 
down and manifests tendency to sleep, but dreams ensue ; giddiness continues, the 
urine free from albumen, bowels quiet ; no cough and convalescence in a fortnight. 
It need not be supposed the wet packing brought on transient pneumonia, for it was 
well known that frequently lung-lesion threatens at the acme and lytic decline of 
spirillum fever, not rarely, indeed, supervening of itself: the chart of this interesting 
case presents no unusual features whatever, beyond the pulse range at fall, above 
alluded to : the concurrence of lysis-tendency and suffering, is also evident. 

21. Phthisis Pulmonalis. — From the known frequency of this disease 
amongst the inhabitants of Bombay, and from the liability of subjects 
under spirillar infection to pulmonary inflammations, it might be sup- 
posed that the conjunction of spirillum fever and hectic would be seen 
sometimes in hospital ; and in fact 5 or 6, at least, of such instances were 
recognised. Occasionally it seemed as if the lung wasting were hastened 
by the specific infection, at other times not so ; nor was it ascertained 
that a predisposition to phthisis might be aroused by relapsing fever. 
Tubercular disease of the lungs was not detected in 74 consecutive fever 
autopsies, mostly of recent illness. 

Two of the earliest cases seen were of Indo-Portuguese youths (a 
class liable to phthisis), who showed in succession bronchitis, pneu- 
monia and phthisis, with relapsing fever and much subsequent exhaus- 
tion ; one also caught chicken-pox in hospital before leaving. The 
following instance is quoted as illustrating blended hectic (pyaemia) and 
spirillum fever, with consequent obscurity of symptoms and need of 
special diagnostic means : — 

Case LXXVI. — F., 30, thin subject (son here with fever) , admitted after a week's 
illness at home, pyrexia, low delirium, bronchitis and some consolidation of right lung, 
jaundice, enlarged spleen, dry tongue, costive bowels : the fever remitted and also 
intermitted, for 7 days, during which time the blood was frequently examined with 
negative results ; some general improvement was taking place, when during a fresh 
exacerbation I detected a few spirilla in the blood (e. t. 104°, p. 108, or not much 
quicker than before), delirium now returned, giddiness and lachrymation without 
pain or redness of the eyes ; next day also the blood contained a few organisms noted 
as not so active as usual, e. t. 101° 4, p. 108; the following m. t. 98^*2, p. 100, 
decline representing the crisis of this brief relapse, the blood now containing some 
large nucleated, granular cells like fatty endothelium. After two days' sub-normal 
temperature, pyrexia again returned, being of similar character and rather more pro- 
nounced, cough grew worse, the sputa became nummular, and the physical signs of 
tuberculosis (sub-acute) were detected in both lungs ; the strength diminishing, 
aphthae appeared in the mouth ; the blood showed only some free protoplasmic 
masses of large size ; after a few days more the patient was removed by her friends. 
Chart appended, No. 13. Plate V. 



208 SPIRILLUM FEVER. 

AiFections of the Circulating System. — Some much-needed infor- 
mation is here wanting, from my having to give up enquiry when the 
materials had been collected. 

22. Heart. — Respecting the significance of post-mortem clots in the 
heart, a pathological rather than clinical import seemed to be indicated. 

The coarser changes of the heart-muscle, such as pallor and softness, 
being noted chiefly in deaths during invasion and second post-febrile 
periods, may be associated with corresponding granular and fatty changes 
of liver, spleen and kidney ; and I here note the main symptom of 
feebleness with rapidity of the heart's action during primary fever, whilst 
later on feebleness with slowness, irritability, and tendency to irregular 
or intermittent action. It is conceivable that death at either stage was 
often hastened by unusual implication of the heart; and a disqualifica- 
tion for physical exertion was not seldom evident in patients, who in- 
sisted on returning to their avocations from restlessness or family needs: 
the future of such individuals remained unknown. 

The smaller cardia,c haemorrhages elsewhere described, were not 
attended with peculiar local signs, so far as I am aware ; nor could 
they, alone, have exerted considerable influence upon general symp- 
toms. ■• 

Inflammation of the endocardium was not proved to be due to 
spirillar infection, early or remotely : nor was it apparent that pre-existing 
disease is necessarily aggravated thereby. 

Inflammation of the Pericardium. — This outer, looser serous invest- 
ment was the commoner seat of both hsemorrhagic and inflammatory 
changes, the local signs still being subordinate : thus, with the striking 
hsemorrhagic pericarditis described in the Chapter on ' Morbid Ana- 
tomy,' neither temperature nor pulse-course was extraordinary ; feeble- 
ness of the heart was extreme, but in the record no allusion is made to 
dyspnoea or palpitation. 

Case LXXVII. — M., 30, washerman, said to have been ill 3 days, was brought 
in a state of low delirium and deep jaundice, t. ioo°-2, p. 120; I found the blood to 
contain numerous spirilla, which after 18 hours on the slide were noted as being un- 
usually large and sluggish : next day pyrexia declined, subsiding by lysis, delirium 
persisted, urine and stools passed in bed, hiccup came on, min. t. 94° "6, p. 98 : 
slow rallying then began, and 8 days later the man, though weak, was in aspect con- 
valescent. The pulse had risen with the supervention of hiccup and diarrhoea (?) 
just after the lowest temperature ; but at last declined to 72, with t. 98° "4. Now 
the relapse came on, and lasted 6 days ; temp, sustained (max. 103°), decline slow : 
the pulse gradually rose, max. 120, always feeble, imperceptible 2 days before death: the 
liver and spleen seemed unchanged, vomiting came on at close of relapse, jaundice 
was again pronounced ; throughout exhaustion, and death with defervescence : 
spirillar blood-contamination was noted by Mr. S. A. as being constant and abun- 
dant. After death, was found copious cerebral haemorrhage, extensive hremorrhagic 
pericarditis, infarcts of the spleen, and inflammation with haemorrhage at lower end 
of ileum ; lungs collapsed, healthy ; liver congested ; kidnies blood-stained : this 
evidence pointing to a blood-change of which the cardiac disease was only one indi- 
cation. I did not think the kidnies especially implicated : no dropsy ; and no signs 
of acute rheumatism, wliich is extremely rarely seen or heard of in the class of patients 
to which this suV;ject belonged. 

Case: L^XX VIII.— Another fatal case was that of a young woman, age 18, ad- 
mitted for chronic diarrhoea, weak and anremic ; she displayed spirillar infection 20 
days after her entering the ward (contagion in hospital), undcrgtjing a pronounced 



COMPLICATIONS — THROMBOSIS. 209 

febrile attack of 9 days, and dying 3 days later with secondary febrile compli- 
cations. Besides the characteristic signs of this fever, there came on palpitation, a 
systolic bruit (? friction sound also), oedema, delirium, jaundice, pharyngitis and epi- 
gastric symptoms : my impression was that both pericarditis and endocarditis had 
been enkindled. The detailed notes being mislaid, I am able to quote this summary 
only ; autopsy not available. 

23. Throtnhosis of Veins. — A single instance was seen : such must 
be extremely rare during remittent fever, but the like is known to attend 
typhus and enteric. Its connection in the following case with prior 
great loss of blood (and resulting alterations in blood-quality), was 
very significant ; yet hardly less so, its occurrence soon after crisis, 
when specific blood-changes are known to occur : perhaps both these 
conditions were concerned in production of the local arrest of circu- 
lation, and the instance of the child's father will indicate which may 
have been most influential. 

Case LXXIX. — F., 8, a thin, weak subject ; admitted in a state of semi-collapse, 
t- 95°j P- 85 ( ? crisis after invasion), rallying was prompt and complete, t. becoming 
normal and p. at last 80-6 : 8 days after admission the relapse suddenly set in, first 
m. t. 104°, p. 112, highfever continued for 4 entire days, the t. ranging I03°-I04° 8, 
p. 130-146, and resp. quickened, she was exhausted, but not distressed, there was 
some splenic enlargement, liver not so much affected, no jaundice : at acme of fever 
e. t. 104° '8, p. 140, resp. 40, skin dry, tongue white and moist, much lieadache, no 
eruptions, no delirium but does not sleep, abdominal organs not more tender, copious 
blood-contamination continues : grs. x. of chloral were gien at bed-time. Next m. 
t. 102°, p. 138, on awakening and being taken in her mother's lap, profuse epistaxis 
came on, almost inducing collapse, both nostrils bled, upwards of ^ pint of blood 
certainly lost, which swarmed with active parasites : under suitable treatment she 
rallied a little, e. t. lOl°'4, p. 132 ; crisis now came on, or became complete, and 
m. t. 98° '6, p. 120, resp. 26, still in depressed state, pupils normal, spleen much 
reduced in size ; e. t. 99°, p. 128. First day after crisis m. t. 98° -6, p. 120, though 
very weak, she had slept and was decidedly improving, spleen still going down ; e. t. 
ioo'8°, p. 120, and this rise probably continued throughout the night. Second day, 
m. t. I04°'6, p. 132 , headache, furred tongue, dry skin, spleen more enlarged, no 
hepatic uneasiness, no delirium, no eruption ; I found her quite conscious, lyinc' on 
the side, with head thrown back ; the spirillum had disappeared from the blood, 
which now displayed clouded plasma and increase of white corpuscles : this rebound 
oft. persisting, e. temp, at 4 was 103°, p. 136, n<:)twithstanding frequent spunging of 
the body and free use of iced water ; skin and tongue dry, no delirium, she had taken 
some liquid food ; two hours later, t. 103° -4, she moans, screams and tosses about, the 
right limbs seemingly more than the left, is still conscious, pupils in mid-state, pulse 
flutte.ing and rapid ; 8'io P.M. the left thigh has become swollen, depression 
following the excitement, and death in an hour. 

Autopsy 1O5 hours afterwards ; froth at mouth ; 1. thigh swollen, of bluish tino-e 
flexed and everted, the pubes swollen and red. Head — pupils of normal dimensions 
brain very pale, all vessels empty, no effusion seen, and no other alteration in sub- 
stances or membranes. Chest — lungs very pale, inflated, no disease ; heart contracted 
scanty pale clots on r. side. Abdomen — pallor general, intestines inflated ; liver 
bloodless, otherwise normal ; spleen very large, not otherwise diseased in aspect, but 
has become permeated by small air-vesicles : kidnies pale and firm, capsules rather 
adherent ; some stellate vascularity of surface, a double ureter on r. side in connection 
with a narrow, elongated organ ; bladder distended with urine, which contained 
flocculent shreds ( ? from mucous membrane), no albumen, bile-pigment present ■ 
other pelvic organs unchanged so far as examined. Left thigh — the swelling is due 
to serous infiltration and the evolution of gas ; muscles and connective tissue equally 
involved, the former being red in hue, streaked with dark blood, and very soft : 
femoral artery pervious, so the femoral vein excepting the presence of loose clots in 
the ham : the long saphenous vein firmly closed with black clot, and so other veins 
on inner side of thigh, even the dtep-seated ; the corresponding internal and common 

P 



2IO SPIRILLUM FEVER. 

iliac veins on both sides of the pelvis, contained blood. This diffused t' ronibosis of 
the 1. thigh was mostly superficiil : embolic masses n 't seen in vena cava or r. si'd e 
of heart : the clots in the saphenous veins wtre of s 'ft consistence : arteries evevy- 
where seemingly healthy. 

A healthy young man while assisting at this autopsy, cut his finger and 3^ days 
later was seized with relapsing fever, suffering considerably from two relapses. 

The father and mother of the above child accompanied her to hospital, the three 
composing a family of pauper-immigrants from the neighbouring province of Kattia- 
war ; date of admission July 2, 1879. The mnther gave an account o{ late fever 
sickness ; the old man (a thorough famine-subject) was actually ill with fever, and 
his blood swarmed with the spirillum ; in him the pyrexia ( ? of first attack) subsided 
by lysis ; a rebound immediately followed, on 4th day t. 104° -4, p. 120, and during 
this post-critical fever no visible specific contamination of the blood : two d^ys later 
death in a comatose state, there being found at the autopsy meningeal cerebral 
haemorrhage, and suppurative inflammation probably thence arising. My impression 
was that here as in the girl, his daughter, the circulation of the blood had become 
impeded about the time of 'crisis,' the fatal effect being alike in both cases, though 
differently brought about. No more characteristic instances than these of spirillum 
fever, were seen by me during the previous two year-;, or when the main epidemic 
was at its height. 

The temperature chart shows- only the unusual feature of a sharp rebound on 
second day after crisis of relapse ; it is not peculiar. 

Complications affecting the Digestive System. — These were nu- 
merous, and including those of the spleen, both frequent and marked. 

24. Inflmnmatiofi and suppuratioji in the neighbourhood of the 
Parotid gland. — This event, to some degree, was noted in 2 or 3 per 
cent, of all cases ; and nearly as often amongst survivors as in the 
casualties. 

It rarely supervened prior to close of specific fever, usually following 
at a distinct interval the crisis of invasion or relapse. I have known it 
appear at the time when a first or second specific recurrence was to be 
anticipated, seemingly taking its place ; but there is no rule in date for 
its advent. 

It was much the commonest after the first attack. 

Oftenest the right side was implicated, or both sides together or in 
succession. 

Similar swellings were not noticed of superficial glands elsewhere ; 
but in the most serious cases, deeper seated parts, as tonsils and fauces, 
were also implicated, either before or after the parotid swelling became 
apparent. 

Nothing peculiar was perceived in the preceding specific illness, 
though usually the subjects were weak and oftenest Mussulman weavers, 
in whom spirillum fever tended to a low type. 

Alone, this complication, single or double, was not necessarily of bad 
augury, and in some subjects convalescence, if delayed in completion, 
seemed unusually prompt to begin : other local lesion conjoined, 
prognosis became decidedly unfavourable. 

Its diagnosis was direct : the form of attendant pyrexia was usually 
low and remitting, seldom sustained ; of 3-5 days' duration, or more 
when both glands were successively involved and suppuration pro- 
longed, the pyrexia not then assuming any particular form amongst the 
many varieties of consecutive fever. The pulse was decidedly 
Quickened : the blood free from spirillar contamination. 



COMPLICATIONS — PHARYNGITIS. 21 I 

Before the formation of pus, the local suffering and intumescence 
might be considerable ; with it relief ensued, and the matter escaped 
spontaneously through the auditory meatus, or by rupture behind the 
auricle, if not let out artificially : there was Httle tendency to burrow 
in the cases seen, or to extend by sloughing. Suppuration sometimes 
became visible 4 or 5 days after fever and pain had subsided, and 
tenseness of swelling diminished ; the quantity of matter might then be 
small : apparent non-suppuration was very rare, and it seemed likely 
that scanty and deep-seated collections of matter were sometimes 
absorbed. Local induration may persist for many days. 

In one very bad case (hospital servant), inflammation around the 
ear supervened on acute pharyngitis ; in the equally serious though less 
acute instance quoted below, it preceded throat affections ; but not 
always was parotitis intensified when followed by renewed fever, as the 
case of a younger man showed, in whom copious suppuration and relief 
were not checked by the relapse. The anatomical relations of the 
parotid at its deeper surface and through Steno's duct, sufficiently ac- 
count for occasional extension of the inflammation : yet I do not 
recollect seeing the front of the mouth and submaxillary glands im- 
plicated, or the nasal cavities : the middle ear, however, might be 
involved, and the larynx. 

Case LXXX. — M., 35, Hindoo famine-immigrant from the Deccan, condition 
fair ; was admitted on 8th day of invasion, t. 104°, p. 1 16, there wtre no urgent 
symptoms but the right side of the face was swollen and hard, and the mouth could 
not be opened : the blood was found to contain several active spirilla of the usual 
aspect. Next day a remission ensued, the bl lod then containing also large granule- 
cells which seamed to have burst, displaying a large nucleus and swarms of minute 
granules in active movement : another exacerbation and the crisis followed, the local 
pain subsiding but not the hard tumefaction. The temp, now remained nearly at 
normal level, the pulse range 60 80, for 8 days, when a relapse suddenly set in 
(spirilla seen on the first day) which lasted 3 days, terminating critically and being 
followed immediately by prompt rebound and high fever of deeply remittent type (no 
spirillum in the blood) : this secondary pyrexia continued 5 days, and ended in 
extreme depression. During this time the local pain and swelling had increased but 
did not advance to suppuration ; great debility and the typhoid state supervening, 
with constant and uncontrollable hiccup, and finally inflammation of the tonsils and 
fauces : some jaundice had also appeared, but the abdominal sym toms were sub- 
ordinate : no swellings elsewhere noted. The patient becoming insensible, was 
then removed by his friends. 

25. Pharyngitis, Sore-throat, Dysphagia, Tonsillitis. — In varying degrees 
were seen in 3-4 per cent, of all cases, and rather oftener amongst 
casualties : sore-throat was commonest just after close of invasion, or 
at its end ; and nearly as frequent towards close of first relapse, or 
shortly afterwards. Its intensity ranged from painful deglutition with 
little visible change to distinct faucial inflammation (including also the 
tonsils and soft palate) : I do not remember seeing a diphtheritic 
membrane, but it happened that the severer cases could not be ex- 
amined closely, and amongst those dying autopsy was not available. 
When mild, the affection lasted only 2-3 days, subsiding spon- 
taneously ; the severer were always further complicated, and ended 
fatally in little longer time : most of the patients were young male 
adults, and Mussulman weavers ; 3 casualties occurred at the ages of 
16, 35 and 55 : general condition decidedly low, and type of fever 



212 SPIRILLUM FEVER. 

tending to typhus or the icteroid form ; examples were seen chiefly at 
later periods of the epidemic. The preceding or attendant specific 
pyrexia was not unusually high, or crisis much marked ; some degree of 
secondary fever (varying, yet remittent and mild) accompanied the 
S3'mptoms, when supervening on the fall ; and the pulse was quickened, 
usually weak. Diagnosis was direct ; dysphagia might be more con- 
siderable than explained by local congestion, paralysis was not noted 
distinctly : on ordinary occasions prognosis was not unfavourable, the 
fatalities always showing other local signs of systemic disturbance ; ex- 
amples of extreme typhus tendency might not, however, entail this com- 
plication : the spirillar blood-contamination was always absent with 
non-periodic pyrexia : anatomical changes not ascertainable. The con- 
nection of sore-throat with earache and deafness was distinctly noted in 
some milder cases. 

In illustration, reference should be made to the detailed Case of H. A., No. X., 
and day, 1st apyretic interval : another is that of Case XXXII. M., 35, a marked 
instance oi typhus icterbdes : after the little pronounced invasion, a rebound of temp, 
not preceded by chills, slight in degree, but attended with depression, hiccup and a 
copious petechial eruption on skin ; there was also dryness and soreness of the 
throat, with much vascularity of the mucous membrane of fauces and tonsils, and (as 
it seemed) some petechise there : on febrile decline these local changes did not pro- 
ceed further, and they did not recur with the subsequent relapse. 

A fatal case was alluded to under the heading of Parotitis (at its termination) ; 
2 others were hospital servants : viz. one a ward attendant, aet. 55> not seen until 7th 
day of invasion, t. 104°, p. 130, the local inflammation was less pronounced than the 
general depression ; liver and spleen not especially implicated : crisis moderate, 
delirium, vomiting, epistaxis, signs of pneumonia, hardness and tenderness of the 
abdomen, restlessness, moaning and finally unconsciousness, with death on 4th day 
after crisis : the secondary fever did not rise above 100°, p. 100, feeble, small and 
intermitting. The other instance offered a similar combination of serious symptoms 
illustrating the worse results of spirillar infection : — M., 16, attendant also in a fever 
ward, J. J. Hospital, general condition fair, but gums discolou ed : the specific 
pyrexia was pronounced, t. io5°'2, p. 136, some epistaxis at acme, a moderate fall 
(t. 99°'4, p. 1 16) and interrupted, the copious blood-contamination persisting till near 
its end : secondary fever at once ensued, some previous bronchitis passed into 
pneumonia first on the left, then on the right side, the liver tenderness and enlarge- 
ment persisting (not splenic) ; for 6 days fever was high and continuous when death 
ensued, which was preceded by typhoid symptoms and great tumefaction of the 
throat and neck on both sides : it was noted that the physical signs of the pneumonia 
were not developed, as usual, posteriorly and below, nor proportionately to the 
respiratory and general distress. Some instances of sloughing sore throat were seen 
at the G. T. Hospital which might have belonged to this series, although the blood 
seemed free from contamination ; for this form of disease is extremely rare in re- 
mittent fever, and diphtheria in native paupers seldom witnessed. 

26. Hiccup. — Spasm of the diaphragm (with closure of the glottis) 
was noted in about 10 p. c. of cases, and almost solely in the severer 
instances or those ending by lysis, or attended with deep jaundice or 
secondary fever : I have however seen it troublesome when no such 
superadded conditions were present. 

An example of minor degree is given in Case IX. at fall of relapse : 
in other instances, also, it was seen at the period of defervescence, 
persisting sometimes a few days longer : the concurrence of vomiting 
was not invariable, nausea and puking might be present ; meteorism 
was rare ; extreme epigastric uneasiness, and either splenic or hepatic 
implication, though usual, were not constant : the state of the bowels 



COMPLICATIONS— H^MATEMESIS. 21 3 

was not uniformly the same, or necessarily abnormal. In a characteristic 
instance of ' black vomit,' hiccup was not noted until gastric haemorrhage 
had probably begun. 

Corresponding to the undefined origin and accompaniments of this 
troublesome symptom, was the uncertainty of its relief by ordinary 
measures, local or general : sometimes many remedies were tried 
in vain. 

Case LXXXI. — M., 30, admitted at close of severe and characteristic primary 
fever, delirium and jaundice being present : crisis moderate, and at once followed by 
a compact non-specific febrile attack ; mid-temp. 103°, p. rising to 120; subsidence 
prompt, but not critical. With the advent of this secondary fever hiccup came on 
and it lasted till the end, then ceasing of itself : general symptoms not increased ; 
there was debility, also constipation, yet no local complication was detected, and 
the blood (frequently examined) showed no other peculiarity than unusual hsemo- 
globin forms. Appetite then returned and convalescence set in with the resumption 
of normal temp., the pulse remaining somewhat above normal. I was unable to 
associate this striking febrile rebound with such abdominal derangement, as the per- 
sistent hiccup seemed to point to. 

In Case XXXII. hiccup appeared at the close of invasion with rebound of tem- 
perature, deep jaundice, sore throat and an eruption of red and purple spots on the 
skin and fauces. I noted that petechise might also have been present on the gastric 
mucous membrane, at this time. 

Another instance was M., 25 ; at marked crisis of invasion hiccup came on, some 
bronchitis and sputum tinged with blood ; no skin-eruption : type of fever low, yet 
as in the above examples, convalescence was fairly complete. 

27. Gastric Hce7tiorrhage. — Congestion, probably inflammation, and 
minute extravasations of blood in the mucous membrane of stomach and 
adjoining tracts being known to occur, more copious haemorrhage occa- 
sionally showed itself (seemingly at identical epoch) either during life by 
the ' black vomit,' or at an autopsy without the previous emesis of blood : 
whether or not the alvine evacuations in any degree owed their frequent 
dark hue at and after crisis, to the presence of blood, I am not able to 
state. 

The two following cases are characteristic examples of this complica- 
tion : in both the occurrence took place with critical decline of fever, 
and was serious enough promptly to cause death. 

Fatal Haematemesis. 

Case LXXXII. — 34, Mussulman, resident in Bombay, ship labourer, a spare 
subject, not starved or scorbutic, was admitted with 5 days' fever, t. 102° and the 
usual symptoms : a few active spirilla in the blood : 6th day, m. t. ioi°'6, p. 100, 
weak, regular, no sweats, much headache and thirst, tongue dry, there is some bron- 
chitis and pain on the right side of the chest, and considerable pain and tenderness in 
the upper abdominal zone, intensest at the epigastrium : no jaundice : the spleen is 
enlarged ; no eruption : he is low and keeps his bed ; one stool. The blood-parasite 
is now very abundant and active. Ordered diaphoretics, saline laxatives and poultice 
tor. side. Vesp. t. 103° -2, p. 116, much headache and thirst, the local signs and 
state of blood unchanged ; one stool. 7th day, m. t. 101° "2, p. 100, little change, 
but spleen probably larger ; there is much mid -epigastric tenderness, no hiccup, much 
thirst ; tongue shrunken, its surface white and dry, edges red ; no sweats ; two pink 
spots on the left shoulder seen : the blood contains vast numbers of spirilla in its 
clouded plasma, a few white cells, little free protoplasm and no free granules. Vesp. 
t. 102°, p. 96, no sweats, much headache and thirst, slight cough and no sputum or 
pain in chest, epigastric tenderness rather less, no fresh eruption ; he has become 
somewhat delirious : one stool (character not noted) : blood-spirilla fewer but active, 



214 SPIRILLUM FEVER. 

they cluster and are sluggish : some quiescent filaments seem to become developed in 
the plasma at this time ; there is granular and vacuolated protoplasm, but no endo- 
thelial cells: is it near the end of invasion? (MS. note). 8th day, m. t. 98°'6, p.96, 
no sweats with this fall, headache now slight, thirst still much, cough as before ; is 
slightly delirious and has some epigastric tenderness ; there is drowsiness and prostra- 
tion, yet not complete crisis : he vomited once in the night (said to have ejected black 
matter, not kept) and now has hiccup, the stomach is distended and epigastrium 
tender : he slept (chloral given), no fresh spots. Blood-plasma tolerably clear, little 
free protoplasm, some large granule-cells, some free granules and short rods, many 
clusters of spirilla very large and active ; red discs shrunken and dispersed in this 
specimen. (Hence here was no real crisis, but rather defervescence by lysis, with 
persistence of blood-contamination. H. V. C.) Vesp. t. 98°, p. 100, no sweats, 
slight headache, much thirst, tongue dry, there is rather more epigastric tenderness, 
hiccup persists, vomiting once in the day (matters thrown away), two stools (not 
seen), depression and wandering of speech ; blood-plasma clouded, fibrillation not 
seen, some white cells and large prot 'plasmic masses, a very few free granules, red 
discs hardly changed ; all is quiet and not a trace of the spirillum to be seen. 9th 
day, continued decline of temp., m. 95^, p. 96, very soft, regular; respirations 40, 
shallow ; skin clammy, no headache, slight thirst, he slept ; tongue moist, no stool ; 
urine very scanty, high-coloured, tolerably clear, albumen ji vol., urinary bladder 
empty ; there is abdominal fulness and uneasiness, and the stomach seems to be dis- 
tended, incessant hiccup, great depression, no delirium but occasi nal restlessness, 
pupils normal, he vomited early this morning some black liquid : vesp. t. 96^*4, p. 
hardly perceptible, has vomited three times since morning and is now moribund 
(death in 2 hours) : state of blood as last evening, with the addition of a few fatty 
endothelial cells. The black vomited matter of the morning was thus described - 
near a pint in quantity, no smell, thick, viscid, uniform consistence, tint in small 
quantities of clear, greenish hue : displays the presence of minute granules, of irregular 
form, dark green colour, also a few round cells probably altered blood of bluish tint ; 
many bacteria and some torulas seen after 6 hours' rest : a few oil globules and no 
other peculiarities made visible by the microscope. Tested by contact with strong 
nitric acid on a white porcelain, surface no play of colours seen after two minutes, 
beyond a faint yellow tinge at the line of junction : conclusion that but little bile was 
present and much blood. Autopsy i hour after death ; stomach and small intestines 
filled with a similar black liquid, their mucous irembrane pallid: the gall-bladder 
contained only 2 or 3 ozs. of glairy, yellow-tinted bile quite diverse to the black 
vomit : no splenic infarcts, or kidney disease : a very few petechijE on both layers of 
pericardium, and in cerebral convolutions at one spot close to superior longitudinal 
fissure : colon and rectum empty. 

In the preceding case there was visible proof of gastric haemorrhage ; 
not so in the following instance, which, like the other, was not brought 
to hospital until near the end of life : their temperature-charts are with- 
out definite character. 

Gastric Hsemorrhage. 

Case LXXXIII.^ — M., 34, also Mussulman resident, working weaver from the 
same loom-factory whence other fever cases (specific) came at same time (February 
1880) : said to have been ill a fortnight ; on admission, t. ioo°-4, p. 128, very feeble 
and small, tongue dry and bmwn, much headache (frontal) pains and thirst; liver 
and spleen enlarged and tender ; he is restless and distressed : vesp. t. 99° '2, p. 106, 
cough and pain in r. mammary region, some dullness on percussion at r. apex, and no 
moist sounds audible : no jaundice. The low temperature and reputed duration of 
fever, did not seem to confirm the suspicion of this case being one of spirillum fever ; 
and in the midst of other engagements, I did not examine the blood whilst fresh ; a 
dried specimen, however, being taken, which after treatment with acetic acid, showed 
abundance of mature and immature spirillar organisms. During the following night 
the t. fell, being 97'''4 at 7 a.m., pulse imperceptible ; it was stated that the 
man became worse in the night, keeping other patients awake by loud moaning 
and restlessness until the end ; there was no vomiting. At autopsy 4 hours after 
death, the stomach was found to contain, besides air, about a pint of black, grumous 



COMPLICATIONS — ENTERITIS. 2 1 5 

liquid ; blackish mucus filled the small intestine, a little feculence in the large: in the 
gall-bladder much dark-brown bile (not like the pitchy liquid), liver pale, spleen large 
and infarcted, kidnies seemingly normal : old pleuritic adhesions on r. side. Urine 
in the bladder, clear, pale, 1016, no albumen, bile present. No other haemorrhage 
detected. 

For other details, see the Chapter on Morbid Anatomy. 

28. Enteritis. — The aspect and comparative frequency of congestion, 
inflammation and petechial extravasations in the mucous membrane of 
the small intestine at its successive portions, being described in the 
Chapter on Morbid Anatomy, I have here to state that the symptoms 
noted during life, which might be supposed to correspond with these 
changes, were not so apparent, or constant, as to permit of special detail; 
and so far as I am aware, none of the local signs noted were peculiar or 
characteristic. It may be the cUnical records are defective, yet this 
vagueness of symptoms is not really incomprehensible, since in the more 
marked cases, there was either general febrile excitement with several 
functional derangements, or prostration considerable enough to entail 
not less obscurity of intestinal signs. Thus, during secondary fever, the 
symptoms were those of general depression rather than of local suffering ; 
and during specific pyrexia, enteric signs might be overpowered by the 
hepatic, gastric or splenic ; or, at most, such indefinite marks were 
noted, as central and supra-pubic abdominal uneasiness, pain or tender- 
ness ; distension or retraction of the abdominal walls, and occasionally 
mucous diarrhoea (often green-tinted). 

If symptoms of this kind be regarded as presumptive evidence of 
enteritis, that complication may be frequent; but passing over the 
slighter and more transitory lesions as being, at present, unrecognisable 
with certainty during life, I have selected for illustration 3 or 4 examples 
of the severer lesions capable of affording some useful information. 

a. Inflammation with granular exudation at end of ileum ; death 
during primary spirillar infection : deep jaundice. 

Case LXXXIV. — M., 25, not emaciated, brought in by the police (who found him 
lying on a roadside), day of fever reputed to be the 5th, much depression, t. 99°, 
p. 126, tongue dry and brown : next m. t. 99° '2, no sweating, p. 140, regular, full 
and very compressible, resp. 48, very shallow, in addition to much headache and 
thirst, general aching pains, slight cough, were noted great distension with air anc" 
acute tenderness of the abdomen, decubitus on the back with knees drawn up, eyej 
closed, jaws rather dropped, yet with this depression not the aspect of typhus proper; 
he was restless at times, turning on the side ; moaning constantly, quite rational, 
pupils rather contracted, heart's action tumultuous though regular, impulse not felt ; 
no chest dullness : no vomiting, he had slept a little, 3 faint pink spots were seen on 
r. shoulder and clavicle ; urine procured after death high-coloured, clouded, 1014, 
albumen a trace, chlorides \ vol., urea gr. \'\<b per oz. I suspected acute congestion 
of the mucous membrane of stomach, ileum, cojon or abdominal walls ; but omitting 
fresh blood-examination, overlooking the rapid pulse, and (after so much experience) 
forgetting that low temp, did not necessarily exclude spirillar infection, I entered 
the remark — ' severe remittent with jaundice, very rare typhous form : ' the man died 
after a few hours ; reported no change and rational to the last. Upon examining the 
dried specimen of blood taken on admission, abundant spirilla were found, and thus 
the correct pathology of the case made clear. Details of the enteritis are furnished 
in Chapter IX.; and it -was pronounced and limited to the end of the ileum : the 
patient passed no stool during the short time he was seen alive. 

Case LXXXV. — M.,24, one of a group of admissions from a common locality, 
was seen on reputed 8th day of illness ; t. 103° "2, p. 120, small and soft ; sevejal 



2l6 SPIRILLUM FEVER. 

fictive spirilla in the blood, which had the usual aspect and coagulated firmly; delirium 
and a condition approaching the typhoid, pupils contracted, conjunctivae vascular, 
deep jaundice, many petechial spots on body, also sudamina ; skin harsh, hepatic 
and splenic te"derness and hepatic enlargement ; next day, the temp, rose to 105° '8, 
p no, small, soft, regular; resp. 40, chiefly abdominal; bowels opened once only, 
in bed : abdominal symptoms subordinated by chest symptoms, and finally uncon- 
sciousness. At autopsy— cerebral haemorrhage and extreme pulmonic congestion, in 
addition to intense vascularity, with extravasation, at end of ileum and beginning of 
large intestine, where the mucous membrane was also covered with granular exudation : 
see Chapter IX. 

The condition presented in the above cases was probably never 
recovered from, and it may not have been approached except in cas- 
ualties ; the following instance doubtless belongs to a similar series. 

b. Inflammation at termination of ileum ; death at crisis of first 
relapse from other complications : deep jaundice. 

Case LXXXVI. — M., 30, admitted towards close of invasion (t. 104°, p. 120) which 
declined by lysis (t. 94°"6, p. 88), general condition the typhoid, much tenderness and 
fulness in both hypochondria, urine and stools passed in bed ; hiccup, florid tongue, 
looseness of bowels (?) : yet rallying was so prompt, that after 8 days he became con- 
valescent in appearance. Then the relapse came on, somewhat gradually, and though 
prolonged for 6 or 7 days, the pyrexia was remittent and never exceeded 103°, p. 120: the 
blood-contamination being again abundant : at its beginning there was some headache, 
tongue moist, bowels regular, liver and spleen hardly affected ; then the man became 
depressed, jaundice increased, no local urgent symptoms, lumbrici vomited ; the pulse 
was rather low and very feeble, becoming imperceptible near the close, when loose- 
ness of the bowels again appeared, with intense depression, and death at critical fall. 
At autopsy besides splenic infarcts, haemorrhages in the arachnoid, pericardium and 
elsewhere, there was seen congestion and inflammation of the ileum, concentrated 
around Peyer's patches, especially at one place about a foot from the ileo-csecal valve : 
higher up the valvulse conniventes being of deep blood gradually diminishing as the 
jejunum was approached : I noted that Peyer's patches were raised, granular in 
aspect, defined, of deep blood hue, the mucous membrane around being highly con- 
gested and blood-stained, over a space of several inches. 

It is worthy of notice that the above case, being long enough under ob- 
servation, manifested all the chief characters of true relapsing fever, and 
this without unusual pyrexial irregularity or complication : a similar 
remark applies to the following instance, excepting that the enteritis was 
more deferred, being also attended with a febrile perturbation,which repre- 
sented one of the many forms of ' secondary,' non-specific fever witnessed 
in both man and the quadrumana. 

Two animals dying of such fever three days after the spirillar crisis, 
presented widely diffused enteritis as the chief anatomical lesion. 

Case LXXXVII. — M., 30, a cachectic subject, with bleeding gums, admitted 
towards close of invasion in a very low state : blood-contamination abundant : t. 
100°, no stool for 5 days, some cough, liver enlarged and tender; after the acme, 
defervescence by moderate crisis, slightly delayed reaction and then a normal level 
for 7 days, pulse rather quick and rheumatic pains being troublesome, but rallying 
was fair and the appetite became gwod. Relapse of spirillar fever then came on : it 
was pronounced and prolonged for 6 days, max. t. 105° '4, p. 128, a decided critical 
termination; the usual symptoms were present— vomiting, considerable pains in the 
thighs and joints, thirst, headache, fulness but not pain in hepatic and splenic regions, 
bowels regular. Secondary fever immediately succeeded to crisis attaining its max. 
on 2nd day, io5°'2, p. 142, then declining yet persisting at a lower level (t. ioi°'2, 
p. 120-130) for 6 days linger, when death took place by exhaustion : during this 



COMPLICATIONS— DIARRHCEA. 21/ 

time the blood-spirillum was absent ; at first bowels costive as at the crisis, thirst ; 
then on 3rd day, very low and pale, t. 101°, p. 130, feeble and running, liver and 
spleen enlarged, tongue dry in centre, rough, red, shrunken, several petechial spots on 
the chest; the typhoid state threatening: so next day, sordes around the teeth, one stool 
at night, heart's sounds feeble, yet distinct : 5th day, some of the spots have disap- 
peared, 4 stools passed in bed at night, said to be thin ; 6th day, is losing strength, 
fulness and tenderness in 1. hypochondrium where the firm spleen is to be felt, one 
thin stool passed in bed, breathing slow, corneee dull and conjunctiva wet, skin 
covered with clammy crust ; the blood now showed no fibrillation, some large granule- 
cells were present, ordinary white corpuscles very few (Mr. S. A. ) ; I had on the 
first day of this rebound noted the red discs also to be scattered and shrunken, the 
blood seeming to be ' in a dying state ' : 7th day, one thin, greenish stool passed in 
bed, abdomen retracted, pulse feeble though regular ; breathing chiefly abdominal 
and shallow, corneas bright, pupils normal ; the body emitted an offeMsive odour : 
8th day, m. t. lOO°*6, p. very feeble and irregular, some tenderness in hepatic and splenic 
regions, sudamina seen in axillae and at elbows, two scanty, thin, and greenish stools 
passed in bed ; he is too weak to turn on the side, some coarse respiratory sounds 
heard on r. side of chest : death soon followed. At autopsy — corpse emaciated, 
tissues sliglitly tinged yellow, some lobular collapse at edges of both lungs, at their 
lower lobes especially ; heart flabby, substance rather pale : liver 47 ozs., aspect not 
unhealthy, permeated by tar-like blood : gall-bladder contains a thin, pale liquid re- 
sembling scrofulous pus ; spleen 12 ozs., pulp not abnormal in aspect, milk-white 
patches on surface behind : kidnies 4 and 6 ozs., cortical substance pale, brownish in 
aspect : t'^e brain was wet, but firm, moderately congested ; the mucous membrane of 
duodenum and beginning of jejunum deeply stained yellow: the ileum presented 
several areas of intense vascularity (see Chapter on Morbid Anatomy, sub loco) : 
the colon thickened granular and vascular. Vide Chart 23, Plate VI. 

29. Diarrhxa. — Was regarded as a complication where of unusual 
severity or incidence, as sometimes happened during pronounced specific 
pyrexia, or just after the crisis ; and though seldom excessive or per- 
sistent, its weakening or depressing effect was then often apparent. 

Native patients coming in late occasionally gave a history of 
diarrhoea, which was not verified by symptoms actually seen : women, 
weak subjects, the intemperate, opium-eaters, those troubled with 
worms, cases ending by lysis and the other severer forms known as 
' icteroid,' were commonest so affected : and it has been noted with 
hiccup, parotitis, lung inflammations, and marked splenic and hepatic 
implication. Most fatal cases at the end showed involuntary signs of 
quasi-diarrhceal flux, and sometimes this might be termed colliquative. 

In general, the connection of diarrhoea with a tender and either dis- 
tended or flat abdomen, was a point for remark ; but the data are not 
uniform in their indications, and this might be anticipated on consider- 
ing the several possible causes of excessive alvine flux. Such were 
mentioned in the clinical analysis (Chapter III.), and here I allude to the 
association particularly with one or other of the intestinal lesions de- 
scribed in the section on Morbid Anatomy : even in the severe cases, 
however, the evidence varied — thus, a hospital matron seized and 
dying during first attack at the onset of moderate specific pyrexia had 
purging and vomiting (reported as bilious) with a distended abdomen ; 
rest was disturbed and in the snatches of sleep there was noted grind- 
ing of the teeth ; santonine being administered no worms appeared 
and much depression followed, without checking of the fever ; death 3 
days later, and at autopsy were found petechial extravasations in 
some cerebral convolutions, with disseminated congestive patches and 
extravasations in mucous membrane of stomach and intestmes ; the 



2l8 SPIRILLUM FEVER, 

combined morbid changes sufficiently accounting for the symptoms 
mentioned. On the other hand, a young man simultaneously infected 
in hospital and dying under similar conditions, had diarrhoea as a pro- 
minent early symptom ; abdominal fulness and tenderness were noted 
towards the end ; at autopsy the stomachal membrane alone was found 
congested : and, again, in a man of 35 (contagion in hospital) there was 
copious diarrhoea before the acme of invasion with much tenderness in 
the upper abdominal zone, yet no general distension ; death took place 
with rebound after a marked crisis, and on section but little morbid 
change was apparent in stomach and intestines. 

Discrimination of simple diarrhoea from the enteric discharges 
of typhoid fever, was not needed during the epidemic ; it might, how- 
ever, be difficult from local signs only : the transitions to dysenteric forms 
were many and gradual, doubtless representing a real assimilation. 
Once, after a latent second relapse brief diarrhoea of choleraic form came 
on, which besides observing a certain periodicity was associated with 
neuralgia and abdominal uneasiness, resembling the occasional relics 
of spirillar infection. 

30. Dysentery. — Tropical dysentery in all forms and degree being 
(like ' fever ') very common in Bombay, its occasional concurrence with 
spirillum fever might be anticipated, without the supposition of direct 
causal relationship : and as acute specific infection often passed 
through all its stages in malarious subjects without any symptom of 
dysentery arising, such instances afforded clear proof of its essential 
independence. Nor could it be said that the new fever predisposed to 
'colitis,' more than equally pronounced malarious pyrexias ; for ex- 
ample, in 66 autopsies of fatal cases, inflammation of the large intestine 
was not present more than a dozen times, if so often ; and then to 
a moderate degree, which surprised me by its Umitation and quasi- 
incidental character. See the Chapter on Morbid Anatomy. 

During 1877-78, true dysenteric symptoms were present in about 5 
percent, of surviving cases, and 10 per cent, of casualties ; this estimate 
being only approximative, for often it was impracticable to distinguish 
their milder degrees from the diarrhoeal. 

They were rare during a first febrile attack, but not after its critical 
close ; and they were seen both during and after the pronounced first 
relapse : amongst pauper patients after discharge dysentery was oc- 
casionally heard of as a sequel, and then probably it was not uncom- 
mon as a cause of death. I have known it supervene only at the first 
crisis, and only with the relapse, being absent at other times ; it might 
be strictly limited to acme, fall or post-critical period, and this well- 
defined occurrence was sometimes striking. Acuter symptoms might 
be marked during specific pyrexia ; they were not seen after its cessa- 
tion when depression comes on, the characters then being those of mild 
or sub-acute local inflammation. A few patients were admitted with 
pronounced dysenteric symptoms, combined with high spirillar fever : 
other local signs, however, were present (as hepatic or pulmonic), and 
since autopsy was not practicable I am unable to state the probable 
share each lesion took at the close of illness. Except as a chronic 
sequence, this complication never seemed alone to cause death: its ordi- 



COMPLICATIONS — DYSENTERY. 219 

nary duration was a few days, the acuter symptoms being noted for 
only 24 or 48 hours (as at critical epochs), or lasting 4-5 days, seldom 
longer than a week. 

Commonly there was some degree of attendant pyrexia during the 
usual post-critical periods, and in severe cases this symptomatic fever 
(hke that of some pneumonias) might be directly continuous with the 
spirillar, blood-scrutiny alone enabling a distinction of dates to be 
made ; but in ordinary cases, the rebound or secondary fever was 
deferred for a day or more after critical decline, the reaction not being 
quite so prompt as with the hepatic and pulmonic complications doubt- 
less oftener beginning at acme. Dysenteric pyrexia has not a fixed 
character, though tending to remit deeply or even intermit ; usually it 
is brief and mild ; and it may be disproportionately low, even with 
troublesome bowel-complaint. 

The pulse has been noted as unusually slow with this complication. 

Dysentery often attended the severer febrile attacks in Mussulman 
weavers especially, also in those ending by lysis, in subjects showing 
malarious and scorbutic cachexia (there being, however, no rule here) ; 
also concurrently with other complications, local or general. 

Its relation to consecutive hepatic abscess has been mentioned ; 
and, as well, its presence amongst hospital patients infected in the 
wards, who were not, however, thereby predisposed to infection. 
Dysentery previously existing was not exacerbated during spirillar 
fever. 

The acute and sub-acute forms were commonest in young people, 
the chronic and sequelar in the old : both sexes were implicated. 

Diagnosis rested on the frequency, painful character and muco- 
sanguineous aspect of the evacuations, together with localised abdominal 
tenderness ; and though usually facile, there were many conditions in- 
terfering with proof. Sometimes the stools contained little more than a 
bloody liquid ; with no visible signs of haemorrhoids. 

The prognosis depending upon urgency of the symptoms : the 
typhoid state and extreme debility being most of all unfavourable. 

The pathological character of the bowel affection under notice is 
open to question, on account of the likelihood, always present, of ordi- 
nary dysentery preceding or mingling with the specific lesions, if such 
there be : besides, the forms of true tropical dysentery have not yet 
been accurately discriminated. The brief duration of spirillum fever, 
especially in relapses, does not seem to favour destructive bowel-lesion ; 
and the singular brevity of some quasi-dysenteric attacks further points 
to the absence of such organic changes, as pertain to ordinary tropical 
forms. Occasionally the symptoms seemed to be of critical character, 
concurring with specific blood-changes and acme of fever. 

Illustrations.- An ordinary form is described in Case No. X. as occurring at the 
close of invasion ; here some pharyngitis also followed ; neither symptom recurred 
with the relapses. Case LXXXVIII. — Acute c^ysentery with spirillar infection : 
M., 13, one of a whole family ill, admitted probably at first relapse, t. io5°-4, p. 120, 
spirilla many; some jaundice, tongue coated at middle, florid at tip and edges; general 
abd minal tenderness and some hepatic enlargement : a small quantity of albumen 
in the urine was noted ; the pyrexia daily intermitted, but did not cease with the 
disappearance of blood-contamination. The typhoid state came on, vomiting, an 
offensive odour from the person, pallor and anxiety of expression, persistent enlarge- 



220 SPIRILLUM FEVER. 

ment of the liver and death by exhaustion 4 days after apparent crisis : the dysenteric 
symptoms were much pronounced, the stools being numerous and of characteristic 
aspect. The lad's chart is reproduced as No. 27, Plate VI.: it shows the paroxysmal 
character of the fever, which throughout exacerbated with chills and abated with 
s\\'eats. Autopsy was not allowed. 

Case LXXXIX. — Dysentery without change of temperature. M., 35, two days 
after fall of first relapse, which was attended with much depression and active 
delirium ; t. 98 -4, p. lOO, profuse sweats in the night, aching pains, and a burning 
sensation in the palms and soles ; the bowels, previously regular, now frequently 
moved, the stools assuming a dysenteric character ; abdomen somewhat retracted, 
and tend, r on pressure along the colon ; this bowel complication lasted 9 days, 
gradually subsiding without other change ; the temperature remaining at normal 
level and pulse but slightly quickened. 

For a striking instance of dysenteric symptoms at acme of first relapse, con- 
current with extreme depression, see Case XXI., Chapter III. ' Crisis.' 

In a lad of 15, sharp dysenteric symptoms came on at the deep fall of relapse, a.. 
mild febrile rebound attending (max. t. 100°, p. 90) ; the loss of blood had probably 
been considerable, and he was so reduced that the evacuations were passed in bed. 
This state lasted three days, after which convalescence began. 

Case XC, below, is an instance of ordinary Dysentery apparently supervening oh 
specific infection ; its cause being possibly other than such infection, and the con- 
junction therefore incidental. 

31. Hepatic Congestion, Inflammation and Degeneration : Hepatic 
Abscess. — The frequency and variety of morbid symptoms and changes 
connected with the liver, in uncomplicated cases of spirillum fever, have 
been already mentioned : the particular association of these phenomena 
not being always possible, in the absence of preciser testing of the 
blood and excreta than I could practise. It was, however, plain that 
in this disease the more prominent hepatic signs have a more limited 
significance than might be anticipated ; and it came within my ex- 
perience to note, at febrile acme, such enlargement, pain and acute 
tenderness in the right hypochondrium, as in other fevers would in- 
fallibly excite grave apprehension of acute hepatic inflammation with its 
consequences, yet all would subside after a few hours at critical defer- 
vescence, nearly as rapidly as the attendant blood-contamination and 
pyrexia ; or, at most, some fulness and soreness might persist for a day 
or two. Judging, also, from the autopsic revelations acute hepatitis, 
in its ordinary meaning, is not a usual coinplication of spirillar infection : 
remarkable gland-changes do, however, occur, and it may be supposed 
that these, in their degree, entail the acute local disturbances named. 
Fatty degeneration ensuing has a distinct clinical significance, even if 
only accounting for the long persistent anaemia of some patients ; as, for 
example, the case of an adult man sinking exhausted 8 days after the relapse, 
in whom, besides some opacity of the arachnoid, diffused patches of such 
degeneration of liver-cells were the most obvious morbid phenomena. 
Further changes will be alluded to under the heading of * Sequelae.' 

Another point of interest is the possible connection of Liver changes 
with Secondary fever. 

Notes of 4 selected cases are before me, all of youths 12-19 years 
of age, who recovered promptly, though displaying high and sustained 
pyrexia of non-spirillar kind : once this followed the invasion im- 
mediately, and three times the first relapse at intervals of 3 days (twice) 
and 22 days : the hepatic syinptoms were invariably mild, and not 
noted at first onset of the fever, they did not last longer than it, or leave 



COMPLICATIONS— JAUNDICE. 221 

any trace behind. I was unable to decide if they had not followed the 
pyrexia or, at least, been due to the same cause as it : yet, in the absence 
of other likely cause of fever, I acquired the impression of its being 
due to parenchymatous hepatic lesion. 

A priori it is highly probable that the molecular changes undergone 
by the liver would occasionally result in residual phenomena, short of 
death ; and such phenomena might be febrile in character. Some 
such supposition is needed to account for the striking absence of 
hepatic complications of an ordinary kind, after acute attacks of 
spirillum fever : the conditions of illness being such, as almost in- 
evitably to entail symptoms of some form. 

As evidence of the little tendency there is here to ordinary hepatic 
complication, I will quote an instance showing that when suppurative 
inflammation does follow spirillar infection, there is found other suffi- 
cient cause for its occurrence. 

Case XC. — F., 25, a weak subject, admitted at the end of invasion ; no spirillum 
in the blood, red discs shrunk and misshapen, coagulation imperfect. With a sharp 
rebound following some cough and abdominal uneasiness, there ensued 4 days of 
quasi-normal temperature and pulse, when the Relapse suddenly set in ; pyrexia now 
high sustained and of 7 days' duration (spirillum seen on 2nd day), much depression 
and a tendency to the typhoid state, without indication of localised disease ; crisis 
moderate, the alvine evacuations few, clay-coloured : then followed a series of 
pyrexial exacerbations, intermitt' nt in character, max. t. I02'^*4, p. 124., much debility, 
diarrhoea with foetid stools not resembling those of dysentery and not becoming more 
unhealthy towards the end, though purging continued unchecked ; this consecutive 
pyrexia ceased after 14 days, and 4 days later she sank exhausted. The blood was 
examined thrice during this period, and as only some peculiar bacterial rods were 
seen, together with large granule-cells and groups of free granules, besides free pro- 
toplasm, it was presumed no serond relapse had happened. At autopsy, brain pale, 
lungs healthy, long, loose, dark coagula in cavities on both sides of heart, spleen, 
kidney and small intestine healthy ; mucous membrane of large intestine throughout 
presented many scattered, small, superficial ulcers, some of which were sloughy in 
aspect, also a few patches of circumscribed redness ; liver weight 2 lbs. 8 ozs., aspect 
healthy with exception of an abscess the size of an almond, situated near its posterior 
border, not furnished with a pyogenic lining, contents healthy-locking pus : prosector 
Mr. B. A. I supposed the small abscess to have been the result of portal pysemia. 

That the spirillar infection may supervene upon hepatic suppuration is shown in 
the following Chapter. 

32. Jaundice.— Q.QiV(m\oxAy apparent, this symptom was sometimes 
striking and at others barely perceptible. The milder degrees of jaun- 
dice were simulated by malarious cachexia or anaemia, and yellowness 
of the native brown skin, or even of the nails, not being always observ- 
able, their detection in the eyes might be obscured by increased vascu- 
larity of the conjunctivae ; the aspect of the urine might be fallacious, 
and I doubt not jaundice was occasionally overlooked, or regarded as 
only febrile sallowness. Sallowness of the skin once seemed to precede 
a yellow tinge of the eyes, and a few cases (not all severe) were seen 
presenting a peculiar fiery aspect, due to supperadded injection of the 
conjunctivae. 

Jaundice was only an occasional symptom, and much less frequent 
than hepatic or epigastric derangements ; it was most prevalent during 
pyrexia, and at the primary attack ; and also in fatal cases. Its occur- 
rence being contingent, characteristic examples of spirillum fever, both 
surviving and fatal, went through their whole course (the latter revealing 



222 SPIRILLUM FEVER. 

typical organic lesions) without exhibiting any perceptible sign of its 
presence. 

A general estimate of surviving fever cases alone, gives the propor- 
tion of 79 in 517, or about 15 per cent, of instances of jaundice. 
During the invasion-attack this symptom varied in frequency from 12 to 
22 per cent, being commonest at later periods of the epidemic and 
amongst Mussulman weavers and low castes ; less frequent amongst 
Hindoos (including most famine-immigrants) at the height of public sick- 
ness During the relapse, jaundice was noted in only 6 to 9 per cent 
of all cases ; this difference is striking. The data concerning second 
and third relapses show, at least, equal infrequency of the symptom. 
Ap-sTetic periods are not included in the above summary, because jaun- 
dice rarely seemed to arise at these stages, and seldom persisted longer 
than a few davs after the fall : it is, however, interesting to notice that 
the svmptom occasionally became intensified in the first, second or even 
third' dav after^vards ; and in 2 or 3 cases, made its first appearance just 
after the crisis. 

The list of fatal cases, embracing 95 instances, showed 52 of jaundice 
in some degree, or a proportion of 56-5 per cent.: this is the main fact 
to be noted here, viz. that the symptom was much more frequent in 
severe than in mild cases, and I may add that it was usually of intenser 
form. 

The grand total of both survivors and the d)-ing, furnished 612 cases 
'with 131 exhibiting jaundice in some degree, or a proportion of 21-4 
per cent. 

, Febrile stages. — Invasion : a yellow tinge may be observed on the 
third day, seldom earlier and usually at a later date, becoming more fre- 
quent towards the end of the attack (e.g. in 35 instances 10 times, at the 
acme or incipient fall) : it may, indeed, be noted first with the critical : 
decline (one-sixth of cases), and commonly augments with its course to 
the end. Prolonged attacks showed a larger proportion of jaundice- 
symptoms than those of shorter duration {e.g. 2 in 3 of estimated 11 
days' duration) ; and also those terminating by lysis. 

Relapses. — Slight jaundice may be detected at the beginning of the 
attack, but it was "usually not until the third or fourth day that this 
symptom became distinct : these days may correspond to the acme of 
attack ; that there is a tendency to come on now in the relapse, as in 
the invasion, appears also from the fact that in a series of cases, jaundice 
supervened 3 times in 10 with the critical fall. 

When this symptom had existed in the invasion-attack, it might re- 
appear early in the relapse, or prove altogether deficient .; although the 
recurrent event be fairly developed, and the jaundice of unusually pro- 
nounced degree at first attack. 

Respecting relapses of briefer duration, these were seldom attended 
with jaundice ; yet in one example (isolated paroxysm) there appeared 
this symptom now for the first time, the liver during the invasion having 
been much affected. The contingency of jaundice at these periods, 
further appears from a case in which its persistence was noted throughout 
the first apyrelic interval and into the relapse, without then undergoing 
any exacerbation or interruption in its slow abatement. 

At all febrile periods, jaundice did not show any certain proportion 



COMPLICATIONS— JAUNDICE. 223 

to local hepatic signs ; and though these were e\"ident, generally, along 
with it, yet they might be wanting. 

In severe cases there was frequent vomiting of bile, but not always ; 
and it occasionally seemed to me as if bile were ejected in this way, which 
otherwise might have entered the circulatiorL 

Non-febriie stages. — First interval : the presence of jaundice was 
limited to the first few days, in a long list of cases ; the proportion of 
cases gradually subsiding until the fourth or fifth day : when persisting 
much longer, this symptom has been noted as intermittent I have 
already stated that it first appears or becomes intensified, sometimes, 
after the critical fall : and the event is not necessarily of bad augur}-. 

Second inter\"al : Jaundice never now arose afresh, and was seldom 
seen after the fifth day in uncomplicated cases : about the time of 
second relapse, it was once seen in mild degree, on arrest of some 
diarrhoea. 

Lesions of the Liver in Jaundice. — In 56 unselected autopsic records, 
the cUnical histon.- showed this s}Tnptom 29 times (51 "8 per cent) with 
enlargement of the Uver 21 times, and in most instances the other cha- 
racteristic hepatic changes : there was no jaundice in 27 cases (48 "2 
p. c.) with enlargement 16 times, and frequently these other changes. 
This statement will suffice to indicate the absence of any peculiar 
organic alterations, in either series ; just as during life there were no 
special s}Tnptoms. 

That the autopsic series differed fi-om the main, only by their greater 
severity, will be apparent on further analysis : thus, in general, jaimdice 
was present at the same periods of disease in both survivors and dying, 
being commonest at invasion-attack (2s in 56) towards and at its close ; 
seldomer at relapse {2 in 7) ; and rare in ap\Tetic intervals strictly so- 
called. A seeming anomaly was the rarity of jaundice in deaths at close 
of first relapse, but the data are xexy few ; and I now proceed to show 
in detail that this sjTnptom was not ver}' strictly related to organic 
changes. From two considerations it is evident that some such relation- 
ship obtained, for presumably organic lesions being most severe in fatal 
cases, with them jaundice attended in like proportion (56 p. c as com- 
pared with 15 p. c) : and, further, the general derangement of the liver 
(as indicated by its increased volume) was somewhat more marked in 
the jaundiced than in the non-jaundiced cases (7 2 -4 p. c. to 5 9 "2 p. c.) 
especially at first attack, which is the most characteristic period of the 
fever. 

At both invasion and relapse, fatal cases were seen in which the 
liver was greatly affected by acute fatt}' degeneration, and still without 
jaundice as a symptom during life : thus, of 13 instances fatal at in- 
vasion, liver larger than normal in S ; and of the 5 negative autopsies at 
relapse-period, liver large, or very large, in 4 : the notes of these cases 
are before me. but it is not required to quote them : and all that I had 
learnt from their study, did not enable me to surmise why jaundice should 
at one time be present in marked degree, and at another equally con- 
spicuous by its absence. I have elsewhere quoted an example showing 
that the liver at the end of fourteen days after a febrile attack marked 
by intense jaundice and subsequent severe relapse, may still not be 
enlarged or altered in general aspect : and this striking instance would 



224 SPIRILLUM FEVER. 

indicate that other fatal changes (possibly of the blood) are not neces- 
sarily attended with marked derangement of the liver. 

In several earlier autopsies, the condition of the gall-bladder and 
bile-ducts was especially scrutinised with reference to biliary obstruction, 
and the results were always of negative import : I do not recollect one 
instance in which there was impediment to the flow of bile ; and ex- 
tremely few in which a deficiency of the secretion was manifest ; in per- 
haps the most striking instance of altered or defective condition of the 
bile (its appearance was compared to thin scrofulous pus), there was but 
slight jaundice, and the stools were green-tinted. 

The form of jaundice witnessed in these fever cases,_ therefore, was 
not that usually attributed to mechanical causes. Bile-acids were always 
present in the urine when searched for : and though long constipation 
was a usual initial symptom, yet the stools were hardly ever paler than 
natural. 

Conclusion. — Jaundice though a most striking symptom when fully 
displayed, was commonly present in moderate forms, which graduated 
to the quasi- normal aspect on the one hand, and on the other to an in- 
tensity of tint hardly to be excelled : these degrees had no absolute 
relation to severity of illness; thus, in 29 fatal cases_ the jaundice was 
estimated as doubtful 2 (once invasion and once first interval), as slight 
6 times (all invasion), as decided 13 times (invasion 9, first interval 2, 
relapse 2), and including 4 instances of so-called typhus form, as 
strongly marked 8 times (invasion 7, relapse i). Similar degrees were 
noted in survivors, but not so large a proportion of the marked cases. 
Further analysis shows this symptom to be connected with the febrile 
state, and chiefly its later period or acme, with ensuing crisis, when 
also the acute liver symptoms and lesions already noted present them- 
selves. 

The limited group of cases displaying that association of deep jaun- 
dice and complete typhoid state which is understood by the term 
Typhus biliosus is alluded to in Chapter VII., Sect. 2 ; at present, I 
observe that the distinction of this group is somewhat arbitrary. 

33. Affections of the Spleen.— Ix. is noteworthy that the more striking 
changes known to occur in the spleen during fatal spirillum fever, were 
rarely indicated by corresponding change or increase of the ordinary 
symptoms referable to this organ ; and I am therefore unable to state 
whether ' infarcts,' for example, ever occurred amongst the survivors, 
there being an absence of local signs presumably indicative of their pre- 
sence, and the attendant general disturbance being possibly due to more 
than one cause. 

The available clinical records of severer cases admitted onlv to die, 
were often so brief that little particular information is afforded by them; 
yet as in the longer seen cases, special fulness or tenderness of the 
spleen was seldom considerable, or in excess of hepatic changes and 
other complications, I am led to suppose that practically it may be im- 
possible to learn accurately the degree, and still less the character, of 
these organ-changes : nor is the common typhoid state itself indicative 
of more than lesion of blood or tissues generally. 

Autopsies showed also an occasional diffused softening of the spleen, 



COMPLICATIONS— URINARY ORGANS. 22$ 

which could not be associated with local signs : limited softening, as of 
infarcts, may have taken place amongst survivors without being indicated 
locally ; localised haemorrhages and even some degrees of inflammation 
are also possible without other sign than those commonly noted of en- 
largement, pain and tenderness. 

It is striking, too, how rarely recent peripheral splenitis was found, 
the following being the best marked, yet little pronounced, instance : — 

Case XCI. — M., 20, gave a history of a defined febrile attack, followed by the 
dysentery complained of oh admission ; the remark was then entered that the case 
seemed one of 'starvation ' rather than of disease : after 10 days of gradual ameliora- 
tion specific fever suddenly set in, which lasted only 3 days, though highly pro- 
nounced, and was followed by prompt secondary fever and death. I he symptoms 
were not peculiar, there was much depression throughout, no cough or sputum, purg- 
ing at the last. Besides showing many infarcts, the spleen was streaked with a little 
fresh lymph at the borders of d. fissure ; there was reddish serum in the left pleura and 
incipient pneumonia of the left lung, chiefly in upper lobe : right side of chest unaffected : 
liver large, pale, smooth ; mucous membrane of colon thickened, granular and vas- 
cular, superficial erosions in the rectum. The connection here noted of splenic and 
left pulmonic changes was occasionally indicated amongst survivors, and correspond- 
ing pains in the left shoulder have also been observed. 

The observations regarding secondary fever submitted under the 
heading of Liver-changes, will, in part, apply to affections of the spleen: 
it being, in my opinion, probable that consecutive splenic changes do 
occur, which are manifested by consecutive fever. 

34. Urinary Organs. — Retention and suppression of urine : albu- 
minuria : renal dropsy. — Towards the close of pronounced primary 
attacks and in complicated cases, surviving as well as fatal, it was not 
very unusual to learn that the urine had been passed during night in- 
voluntarily, and the urinary bladder might be found distended ; at the 
same time, faeces might or might not be evacuated, these symptoms 
being such as noted in other severe diseases. Retention of urine may 
supervene also with debility, some days after cessation of fever. 

An actual suppression of urine was doubtless rare, even of brief 
duration ; yet at the critical fall it clearly appeared that the quantity of 
urine formed was for a time diminished : vt'de Chapter III. of this 
Section. 

Renal complication. — At autopsy it is found that during fever, the 
kidnies are similarly and as often implicated as the liver and spleen ; 
and clinical observation showed that after cessation of fever, the renal 
changes doubtless persisting were as obscurely indicated as the splenic 
or hepatic. Even repeated attacks of specific fever did not entail lesions 
detectible at the bed-side. It seems almost anomalous that, whilst at 
high pyrexia the glandular epithelium becomes swollen and granular, yet 
the urine remains pale, light and clear ; and briefly, as at present in- 
formed, I am unable to name any lasting, serious or peculiar renal 
lesion which is certainly due to the spirillar infection. 

In some severer cases examined with care, during life the urine fur- 
nished no evidence of acute nephritis, when after death the cortical 
uriniferous tubes were found, in parts at least, distended with turgid and 
clouded epithelium. 

Respecting deferred sequelar states, fatty degeneration of the gland- 

o 



226 SPIRILLUM FEVER. 

cells is the only change known to me ; and in its production other in- 
fluences, such as previous state of patient, malaria and intemperance, 
may have had a share. Late autopsic experience demonstrated that 
amongst the poorer classes at Bombay, chronic renal lesion was far less 
common than in the lower classes of large European towns {e.g. London 
and Berlin) ; thus, out of 74 consecutive necropsies of fever subjects, 
only 2 revealed the presence of granular kidney. 

Albuminuria. — I have elsewhere remarked that at critical stress of 
spirillum fever, a trace of albumen often appears in the urine : but tube- 
casts or granular epithelium, were not seen by me at this time ; nor did 
the presence of albumen appear to be associated with urgency or pecu- 
liarity of symptoms. 

The following case is worthy of record from its complicated cha- 
racter, the form of pyrexia presented, and the state of the blood : — 

Case XCII. — M., 40, Goanese cook, of cachectic aspect and intemperate habits, 
was admitted with fever and anasarca reported of 15 days' duration ; there was pre- 
sent also pains in the limbs, basal pulmonic congestion, feeble action of the heart, 
little perceptible change in liver and spleen : urine scanty, high-coloured, turbid, 
1012, acid, albumen ^ vol. : the man was found to have taenia. Subsequently the 
urine became pale, 1007, albumen very scanty ; the anasarca for a time increased and 
then diminished, when fever returning his friends took him away, 24 days after ad- 
mission. During his stay, the pyrexia daily remitted strikingly, or intermitted : it 
gradually declined to normal from 104° -6 during the first six days ; for three more it 
remained near normal, and then a second series of 6 paroxysms occurred, also dimi- 
nishing after the first ; there next followed an apyretic interval of about seven days, 
when again smart paroxysmal fever occurred, and four days later the patient left in a 
bad state. Blood -scrutiny was made at the febrile epochs, with negative results 
except on 2 or 3 occasions, when a small active organism comparable to an immature 
spirillum was detected : prior to these also some vacuolated protoplasm, and after- 
wards large nucleated, pale cells. I saw this patient frequently and regarded his case 
as one of spirillum fever modified in some way, and attended with renal disease pro- 
bably not recent. 

Post-febrile Albuminuria. 

Case XCTir.— M., 25, admitted towards close of invasion, which declined by 
lysis, and, though uncomplicated, was accompanied with a dry low state ; at the end, 
purplish spots and oedema of both feet, looseness of bowels, severe pains in limbs ; 
4 or 5 days later retention of urine with pain in the bladder, and a small amount of 
albumen in the pale, clouded urine, sp. gr. 1009, phosphates deposited, the symptoms 
indicating also slight cystitis; temp, slowly declined and improvement ensued under 
treatment by strychnia. There was at this time some desquamation of the cuticle of 
the limbs : the specific infection had been marked, and there were some blood- 
signs of a latent relapse with the above-named symptoms. 

The association of albuminuria with abortion was not enquired 

into. 

The not infrequent brief post-febrile oedema of the feet (dorsum) and 
sometimes the hands, face or trunk, was not found to be associated with 
albumen m the urine. 

35. Abortion. — This event was noted in the first group of fever- 
patients coming under notice at the Relief camp in April 1877, and 
subsequently 4 or 5 times ; omitting the unproven instance (though a 
highly probable one), the ages of 5 women aborting ranged from 16 to 
30 years, date of event 4 times during invasion, viz. thrice at about 
mi J- period and once near crisis; once it occurred 5 days after an 



COMPLICATIONS — ABORTION. 22/ 

invasion-attack not much pronounced, but terminating bj' lysis and 
attended with depression, jaundice and deUrium ; no further accident 
happened, and all patients recovered. The fever, as seen, was not un- 
usually high, but tended to be irregular, and rapidity of pulse was a 
common feature : relapses occurred 4 times certainly, and once a second 
recurrence : blood infection was demonstrated always, and in the cases 
I saw abundantly — once the blood being amazingly filled with clusters 
of active spirilla. Complications were rarely present, and none unusual 
followed, as a rule : the husbands of two of the women were known to 
have fever. 

The expelled foetuses were of ages estimated at 2 to 6 months, only 
the oldest showing brief signs of life : rio unusual aspect was noted in 
these bodies : state of the placenta generally unknown ; but one ex- 
ample I saw appeared quite normal. Examination of the fcetal blood 
did not reveal the presence of the spirillum on two occasions, although 
the maternal blood might contain several parasites. 

From the notes preserved it appears that, in general, the fever was 
of rather low type : great extremes of temp, not being seen here : the 
following memoranda refer to the last instance met with. 

Case XCIV. — F., 30, resident in a fever quarter, health fair, 6 months advanced 
in her fifth pregnancy : admitted on 7th day of first attack, m. t. 104°, p. 120, some 
hepatic tenderness and splenic fulness, bowels costive, much headache, no sleep, 
pains in the limbs ; broncliitis, uterine uneasiness and the os a little dilated. Next 
day ; had been restless at night, fever peisisted and the uterine pains increased ; e. t. 
1 04° '2, p. 128, r. 30, headache severe ; blood loaded with the parasite which also 
appeared in the sputum ; labour was completed the same night, expulsory efforts 
being forcible and after-contraction complete ; the foetus is said not to have breathed, 
but the heart's action persisted for nearly an hour. Next morning 1 examined the 
foetal blood going to and returning from the placenta, without perceiving the spirillum; 
the liver was pale, its blood containing nucleated cells and liberated nuclei, the spleen 
was very small, not congested but compact as a piece of flesh, nothing peculiar being 
noted in its blood : a minute fragment of clot from the maternal side of the placenta 
contained some quiescent spirilla, though not so many as were seen in the woman's 
blood. The acme of attack probably occurred the night of abortion, for in the m. 
t. 105°, p. 140, resp. 38 and dyspnoea considerable, the patient appearing distressed : 
relief shortly ensued with copious sweating : secondary febrile paroxysms appeared 
for a time (blood-scrutiny negative) without marked local signs, and the woman 
rallied in a remarkable manner after cessation of the specific pyiexia. 

Extreme derangements of the Menses during illness, did not come 
under notice. 



Q 2 



228 SPIRILLUM FEVER. 



CHAPTER VI. 

ANTECEDENTS AND SEQUELS. 

Antecedent Sickness. — Amongst 31 instances of hospital patients 
acquiring spirillum fever in the wards, 4 were healthy infants or children 
infected from fever-sick parent or family ; of the remaining 2 7 persons, 
1 1 were admitted for ague or remittent fever, 5 for diarrhoea or dysen- 
tery, 4 for organic lesion of nervous system (all women), and i under 
each of the following heads — chronic bronchitis, dropsy, hepatic abscess, 
lumbago, scurvy, constitutional syphilis, debility after cholera. Total 
males 20, females 7 (showing a decided preponderance of women pro- 
portionately to numbers of sexes in the medical wards) ; general state of 
males, 12 bad, 8 fair ; of females, all in much impaired health. Mean 
age of both sexes 30 years t time in hospital prior to seizure, 10 to 
77 days. 

Of the specific attacks, 1 1 were known to be relapsing (a second re- 
currence not seen) : of the remainder, 10 single attacks ended fatally, 
10 were not apparently followed by a recurrent-attack, but some of these 
left hospital too early to render it certain a relapse might not occur. 
The mortality was rather over 30 per cent, and equal in both sexes : 
this datum seems to indicate the unfavourable influence of bad health, 
prior to infection ; but age was also concerned, for the mean age of the 
dying was either considerably beyond the mean or exceptionally below 
it. 7 of the relapses were seen in the 1 1 more malarious subjects, none 
amongst the 5 dysenteric, 2 amongst 4 palsied women ; no relapsing 
case died, all the 10 casualties happening at invasion-attack. 

There being no absolute uniformity of illness amongst ordinary 
subjects, it becomes difficult to estimate correctly the predisposing or 
modifying influence of antecedent sickness ; and on considering the 
above instances I am unable to perceive a rule determining their com- 
parative frequency and intensity. It might appear that a malarious 
taint predisposed to spirillar infection, but conditions are here complex, 
and the cases too few for special inference. Some of these acquired 
illnesses were striking from their brevity and irregularity of pyrexial 
manifestation, others were almost typical, and a few unusually pro- 
nounced : on the whole, the variety of fever seemed greater than 
amongst ordinary hospital patients ; yet interesting as is this datum, 
murh stress cannot be laid on it, since hospital admissions may not 
include slighter attacks of fever staying at home, and did not probably 
include others speedily ending in death outside. 

It happened that the above patients were all free from febrile, or 
other acute symptoms, at the probable date of their infection ; and 



SEQUEL.^. 229 

hence there are no means of judging if the spirillar contagium can be 
implanted in the system, at a moment when other acute disease is 
present. From many data, it is known that once implanted, its de- 
velopment is not likely to be materially checked. 

Sequelae. — Experience has shown that in time (as well as form and 
degree), it is impossible to sever abruptly the rarer events from the 
usual : however, phenomena supervening distinctly after close of the 
last febrile attack may for convenience be regarded as sequelar. They 
are commonly chronic in character, but are liable to exacerbation and 
repetition. 

The sphere of observation at Bombay was not favourable to dis- 
crimination of the longer deferred effects of spirillar infection, owing to 
both rarity of cases sufficiently followed out, and the wide prevalence of 
another cachexia (the malarious) amongst the poorer classes. In a 
practical sense, amongst the surviving majority complete restoration to 
health was the rule : some instances were known of patients dying after 
their discharge from previous organic disease probably accelerated by 
fever-illness, or from dysentery following the fever ; and a few were 
re-admitted to die from bowel-complaint, also seemingly colliquative. 
In such cases it is difficult to apportion the influence of specific in- 
fection per se, and hardly less so in the milder sequelar affections ; for 
other deteriorating influences might always be concerned. Bearing in 
mind the probable pathology of the disease under consideration, the 
observer will apply general rules according to custom and personal 
judgment ; pending the receipt of information adapted to strictly 
accurate decision. 

From what was seen at Bombay, it appears that the spirillar sickness 
may exceptionally inflict both lasting lesion of body-nutrition, which if 
originating in certain abdominal organs, becomes manifested by general 
debility, emaciation and ansemia ; and also lesion (essentially nutritive, 
too) of particular -organs, as of the brain {vide Case LVI. Chap. V., 
and also LV. which connects the two series here indicated). 

As examples very significant of mortality amongst the indigent 
and aged, during public dearth and resulting disease, the following 
cases will suffice : — 

Case XCV. — M., 25, a sailor, tramp from Madras, 8 days in Bombay and suffer- 
ing 12 days from fever (which therefore seemed to be acquired before his arrival in town), 
admitted May, 1878 : it happened I then saw the man and ascertained the presence 
of abundant blood-contamination ; otherwise, as the febi'ile symptoms were slight and 
not peculiar, subsiding next day (spirillum now absent), the true nature of the case 
might have remained unknown. A highly cachectic subject, jaundiced, both liver 
and spleen enlarged. For 34 days there was an almost level temperature, about 
the normal, pulse variable, and he seemed to be slowly gaining strength, when 
smart fever came on, deeply remitting, and in 2 days more he died (blood not 
peculiar in aspect at this time). At autopsy there was found incipient pleuro-pneu- 
monia on right side, liver and spleen of enormous size, the kidnies probably fatty. 
The man himself allowed his habits to be intemperate, and he had long been exposed 
to malarious influence. 

Case XCVI.--M , 50, a miserable subject brought by the police in a low, 
delirious state with moderate fever ( ? end of invasion), but copious blood-con- 
tamination which alone determined the diagnosis : rallying was very slow, some 
bronchitis followed, general pains and gradual loss of strengUi ; bed-sores appeared, 



230 SPIRILLUM FEVER. 

and he sank exhausted 53 days after the cessation of specific fever. Through over- 
sight an autopsy was not made. 

Case XCVII. — M., 60, weak and pallid, was admitted at close of invasion, and 
10 days afterwards underwent a pronounced relapse (spirilla numerous), there were 
also indications of a second relapse 13 days later: nearly a month subsequently or 
two months after admission, he sank exhausted : previously there being no apparent 
complication of liver and spleen, but a jaundiced aspect, spongy gums, oedema of the 
feet, some swelling (temporary) of the r. elbow-joint, and finally slight pyrexia at 
night. At autopsy, there was seen fatty degeneraton of heart, liver and kidnies, 
spleen large, dark and soft, petechial extravasations in the stomach aad small 
intestines and old mucous erosions in the colon and rectum. The unfavourable in- 
fluence of advanced years was here manifest. 



231 



CHAPTER VII. 

CLINICAL MODIFICATIONS OF SPIRILLUM FEVER. 

ESSENTIAL AND INCIDENTAL: MODIFICATIONS FROM CONJOINED ENTERIC, 
TYPHUS AND MALARIOUS FEVERS. BILIOUS TYPHUS. 

So far as these are yet known, they may be arranged as follows : — 

I. Essential modifications. 2. Those due to attendant conditions 
and complications. 3, Those attributable to supervening diseases. The 
form known as ' bilious typhus ' is considered apart, at the end. 

1. That under similar conditions, the fever varies greatly in intensity has 
been already shown : thus, illness may be mitigated so far as to consist 
of only a single and not severe febrile attack ; or if relapsing, the recur- 
rence is represented by a mere febricula. In healthy monkeys, I found 
the sole result of infection to be often such febricula ; and, possibly, no 
more may occur in man himself On the other hand, illness may induce 
death at invasion or relapse. 

As regards modifications of character, it appears that under similar 
conditions, illnesses may differ otherwise than in their intensity : also a 
particular group of symptoms, indicating a particular modification of 
contagion, was sometimes seen in small collections of persons infected 
from a common source, as hospital employes, members of a family, 
husband and wife. No doubt in some of these instances a common 
personal predisposition was present, but this is hardly likely in others 
where race, age and sex were diverse : for details see Chapter on 
Etiology. In an experiment, I generally found the same material 
produce similar effects on two or more animals inoculated with it ; and 
in different experiments, somewhat different effects were noted. Such 
natural tendency to variation has to be borne in mind, whilst estimating 
the modifying influence of incidental conditions. 

Previous infection. — So far as appears from four or five cases known 
of relapsing fever being repeated in the same subject, at different dates; 
and from similar instances of repeated inoculations of the monkey, a 
previous illness does not necessarily modify, to a considerable extent, a 
later attack from another infection. Such later attack may, or may not, 
resemble the earlier one. 

2. Modifications due to race, caste and physique, or to sanitation 
and season. — Hindoo immigrant agriculturists from the Deccan, seen 
chiefly in 1877, displayed the fever in pronounced and probably typical 
form. During 1878 were seen more Mussulman weavers from Hindu- 
stan, of feebler physique and oftener with malarious cachexia, who ex- 
hibited fever of less sustained form, more depression, more frequently 
the eruption and head symptoms, with other marks of typhus-like type. 



2 32 SPIRILLUM FEVER. 

Throughout the epidemic, low-caste classes from various districts, chiefly 
serving as town-scavengers and dustmen, and of inferior physique, 
suffered severely, yet not in uniform fashion. The few Eurasians seen 
at various dates, showed fever of continuous type or complicated with 
subsidiary pyrexia. All these classes live mostly on, though not ex- 
clusively, on vegetable food : there was no reason to suppose that diet 
operated as a considerable modifying influence, nor could such be attri- 
buted directly to mal-hygienic influences, or even to personal destitution 
and want. Doubtless paupers suffered most severely, yet not from 
different type of disease. 

A particular modifying effect of season upon the character of the 
fever was not apparent, nor was there noticed any real change from year 
to year amongst similar classes of men ; the group of patients treated in 
1879, showing equal diversity of form and degree to those seen in 1877. 
The sphere of observation at hospital was too narrow to permit of 
wide generalisation, but so far as appeared, the spirillum fever preserved 
ail its main characteristics throughout, only in the worst class of subjects 
tending to ass'ume a low and less regular form, as other acute pyrexias 
would ; 3'et, I could not help remarking, to less extent than occurs with 
them. When the num-ber of such subjects is considerable, the character 
of the ' epidemic ' may be said to change accordingly ; and when they 
become fewer, the commoner or average features of the disease again 
predominate. The modifying influence exerted by pre-existing disease 
has been alluded to in Chapter VI,; it was not invariably manifest, and 
greater modification could hardly be anticipated from general influences 
like those above-named. Instances were noted in which the fever 
maintained its essential characters amongst subjects just recovering from 
cholera, or affected with malarious and scorbutic cachexia, or with 
leprosy, cancer and elephantiasis : and, at most, these attendant compli- 
cations might lead to depressed or irregular development of specific 
symptoms, the death-rate being higher without unusual frequency of 
spirillar accidents. 

Modifications due to local disease attended with pyrexia, are de- 
scribed in the Chapter on Complications. 

3. Modifications from co-existing or supervening febrile diseases. — 
There is no valid reason for doubting that more than one specific infec- 
tion may be present in man, either at the same time or in close succes- 
sion. First, as to co-existence ; supposing that a ' continued ' or a sus- 
tained ' malarious ' fever concur with the spirillar, its presence would 
become apparent during the intervals of spirillum fever ; the combined 
result being a quasi-continuous pyrexia displaying at certain periods the 
blood-signs and other symptoms of this fever, and at other times the 
arjpropriate indications of the intercurrent disease, as of typhus, enteric 
or remittent fever; and, a priori^ there may seem no great difficulty in 
the diagnosis of such composite cases. Yet apart from the fact that the 
fevers last named, possess no pathognomonic mark whereby their presence 
can be invariably established, practical difficulties do arise from certain 
variable features of the spirillum fever itself; such as its occasional 
prolonged defervescence by lysis, its liability to local complications like 
those of other fevers, and especially its not rare adjunct of secondary 
fever. In more detail, during lysis the pyrexia and general symptoms 



CLINICAL IVrODIFICATIONS. 233 

may simulate typhus, amongst complications are bowel complaints sug- 
gesting enteric, and remittents as well as typhus may be imitated by 
the consecutive fever. The skin eruption would not have afforded any 
aid at Bombay.^ 

Concurrence of tropical Enteric fever. — Typhoid is known to prevail 
in Bombay, and several cases passed under my notice in 1877-78 {vide 
Appendix B) ; hence it was possible that occasionally mixed enteric and 
relapsing fever might occur. Only a single doubtful instance was, how- 
ever, seen.^ 

Case XCVIIL— M., 18, famine-immigrant, admitted in June 1877, four days in 
the town and twelve days ill with fever : emaciation and the typhoid state imminent, 
conjunctivse much discoloured, no eruption visible, no diarrhoea, gurgling in the r. 
iliac region. Mental oppression, low delirium, sudamina and continued decline of 
strength during the four days he remained alive. The blood was examined twice by 
myself, with negative results ; but on the case is an entry that the spirillum was seen 
at tstimated 13th day of disease, m. t. 105°, p. 130 ; the authority for this entry was 
unknown to me. At the autopsy, besides pulmonary apoplexy, there was sloughing 
and ulceration of Peyer's glands at the lower end of the ileum, and also of the solitary 
glands of the large intestine ; kidnies normal, liver unchanged, and spleen unaffected 
(weight 5^ ozs.) I was not present at the autopsy, but this record is made by a 
competent hand. 

The chart is too brief for analysis ; the aspect of the spleen is not that noted in 
spirillum fever. 

' Whilst Griesinger on the ground of an abundant eruption of roseola seen in some 
severe epidemics, would recognise a mixed form of T. recurrens and T. exanthematicus 
(' Infectionskrankheiten,' 2nd ed. 1864), Wyss and Bock from experience at Breslau, were 
not disposed to do so ('Studien ueber Febris recurrens,' 1869): still later experience at St. 
Petersburg has led to a fuller development of views ; thus, it is stated that clinical obser- 
vadon has shown that ' in the course of enteric and typhus certain peculiar symptoms 
appear, which indicate the presence of relapsing fever ; unusual tepperature-changes, 
sweats, only s ightly marked head symptoms, clinically pronounced changes of liver and 
spleen, the outbreak of primary vermilion-tinted petechias quite at the beginning of the 
attack ; these considerations siipplemented by the pathological alteradons undergone by 
the spleen, have convinced us of the possibility of concurrence in time of enteric, typhus 
and relapsing fever ' (' Zur Frage iiber die Mischforinen des Typhus,' aus der Clinic von 
Prof. Botkin, mitgetheilt von W. M. Borodulin. St. Peteriburger Mcdicinische Wochen- 
schrift, 15 Julie, 1878). Five selected cases are narrated, with charts, and inference is 
based upon the presence of blood-spirillum and certain symptoms occurring at intervals in 
the course of illness. In the same journal for 16 May, 1881, is a review of Dr. S. Lebe- 
dew's analysis of 216 cases of mixed typhus seen in a temporary hospital at St. Petersburg 
during the first half of 1880; here the concurrent form was conjoined with typhus 123 
times, with enteric 73 times, and in 20 cases it was supposed all three fevers coexisted to- 
gether : perhaps this last idea (based upon charts) would be regarded sceptically, without 
necessarily discarding the whole. I am fully of opinion that the ordinary temperature- 
charts are often an insufficient, and sometimes an unsafe guide in determining the nature 
of febrile complications. 

2 Three cases at St. Petersburg (Borodulin, loc. tit.) showed a condnuous and gradiially 
declining pvrexia of 20-25 days in two recoveries, and a more prolonged and sustained 
pyrexia of 36 days in a fatal case, where was found ulceratirin of Peyer's patches in the 
ileum, double pneumonia and disseminated suppuration in the r. kidney, together with 
hemorrhagic splenic infarcts, and seemingly fatty" changes of liver and kidnies. Petechiae 
and roseola were noted on the third day of disease, the typhoid state soon set in, diarrhoea 
was present : the blood spirillum was found on two separate occasions, which I take to 
represent invasion and first relapse ; possibly a second relapse occurred. Only the intes- 
tinal change seems here remarkable, and in conjunction with the other complications, its 
significance may be variously estimated. Diagnosis in a fourth case I regard as more 
doubtful, the chart and symptoms resembling those of secondary fever. 

A similar interpretation is applicable to a surviving instance recorded by Dr. Rabagliati 
at Bradford [Edin. Med. Jo., vol. xix. , Dec. 1873). No eruption ; no blood examinations 
at this date : the chart shows recurrence of fever shortly after end of first relapse, being 
sustained (with a mid-intermission) and prolonging the illness to 36 days. 



2 34 SPIRILLUM FEVER. 

Concurrence of Typhus. — The identical relations of this disease as 
regards not only locality and date of prevalence, but also the class of 
subjects affected, and originating and propagating conditions, would of 
themselves suggest the probability of typhus being associated with re- 
lapsing fever more intimately than enteric ; and especially during severe 
epidemics, is it likely such association would be marked. 

At Bombay, it was evident on first detection of relapsing fever that a 
' low type ' prevailed more frequently than not, and time deepened this 
impression, for as compared with most European records, there was 
noted here early depression, cardiac debility, increased prevalence of 
head-symptoms and an augmented mortality ; an ineffaceable eruption 
was sometimes seen, and whilst the specific pyrexia, seldom high, might 
not vary much in its course, yet the febrile attacks (especially the first) 
were often prolonged, or ended by modified crisis, or were followed by 
secondary fever of equally ' low type,' which proved fatal. 

Upon these grounds it was surmised that the local epidemic possessed 
a distinct 'typhus taint,' which was displayed in serious modification of 
the ordinary symptoms of relapsing fever ; but whether or not veritable 
typhus was actually co-present in hospital cases, could not be proved 
from symptoms alone (for these might be changed during combination), 
and a pathognomonic sign of typhus is yet wanting. 

Very early in my enquiries the following instances occurred, which 
were then regarded as showing the conjunction of idiopathic fever (pro- 
bably typhus) with the spirillar: the fact of their being both youths is 
not in favour of that inference, which was based on general symptoms 
and aspect. 

Case XCIX. — M., 14, resident, works in a spinning-mill, admitted with a history 
of previous illness and for the last 5 days persistent fever, emaciated and weak, tongue 
dry and glazed, lips dry, hepatic tenderness, cough with bronchial congestion, e. t. 
103° '4, p. 124, slight delirium, no stool ; for the next five days the temperature re- 
mained high and continuous, the lad was drowsy and stupid-looking, delirious at 
night, skin always dry, cough increased, no eruption seen, urine free from albumen, 
face puffy and then the legs : probably slight pneumonia was developed. N¥ith less 
continued fever, the tongue became moist, delirium less marked, cough looser, pros- 
tration more apparent : for 8 days longer the fever remitted only, not every day. and 
max. temp, not below 102° ; it then declined more decidedly and gradual improve- 
ment began, splenic enlargement and tenderness, temporary diarrhoea, about this time, 
with pain in r. shoulder (no jaundice) : a brief relapse occurred on 31st day of 
disease. The blood was examined daily at first, and on one occasion showed many 
spirilla : the medical officer in charge noticed the case as one of ' typhus,' and judg- 
ing from appearances correctly, although the chart (No. 14, Plate V.) suggests rather 
a concurring remittent. 

Case C. — M., 12, immigrant, admitted on estimated 8th day of illness with high 
fever, hepatic complication and cough, some night delirium and drowsiness at day ; 
jaundice appeared and the typhoid state began, some pneumonia being probably de- 
veloped ; with decline of pyrexia improvement ensued, though slowly : spleen en- 
larged, but no other abdominal implication ; febrile paroxysms occurred with exacer- 
bation of these symptoms : the subsequent ana;mia was great : no pains : recovery 
good. Eruption not noted. The blood was many times examined and the spirillum 
seen on 12th and 13th days, and again on 20th day, when rises of temperature also 
took place : in the final paroxysm, I failed to perceive blood-change. Chart like 
tliat of the last case. 

Under ordinary circumstances typhus fever has not been known at 
Bombay, nor were distinct examples seen during the late public sick- 
ness ; therefore, if this species of continued fever were ever present, it 



CLINICAL MODIFICATIONS. 235 

must have been almost solely in connection with the new disease ; and 
of such conjunction the evidence seems defective. The common condi- 
tions under which nearest approaches were made to typhus occurred, 
first, when the spirillum fever was prolonged at the last and slowly 
subsided by lytic defervescence ; and, secondly, during certains kinds of 
reactive or consecutive fever. The symptoms supervening at ' lysis ' 
have been already described ; they may usually be termed typhus-like, 
and since becoming acquainted with the late literature of this subject, I 
am somewhat surprised to find so little special notice taken in Europe 
of a modification very manifest at Bombay : perhaps non-use of the 
microscope in all severe illnesses, may partly account for this deficiency. 

Secondary fever simulating typhus has also been alluded to, the in- 
terpretation here placed being one forced upon me in the course of 
enquiry, especially by the fact that infected quadrumana sometimes dis- 
played such fever, and there could be no suspicion of typhus admixture 
there. See Appendix B, and Charts in Plate VIII. 

In brief, it is my opinion that the phenomena sometimes regarded as 
evidence of the co-existence of typhus with relapsing fever may be ex- 
plained in a less recondite manner : they were witnessed at Bombay, 
where typhus is not supposed to exist, and the chief of them also in 
animals literally wild. ' 

Concurrence of Malarious Fevers — In general, all the occupants of 
the native town of Bombay are exposed to malaria, the influence of which 

' Prof. Wunderlich quotes a few references in allusion to the occurrence of lysis in the 
so-called bihous typhus, and afterwards Wyss and Bock noted that in ' bilious typhoid ' 
defervescence, often without sweats, ' tritt haufiger lytisch ein.' Others go further, e.g. 
Dr. Rabagliati s account of the epidemic at Bradford is illustrated by charts, of which 
Nos. 2, 4 and 6 display lytic decline of fever after invasion, and these alone were selected 
by the author as illustrations of ' typhus ' after relapsing fever : in No. 2 the pyrexia was 
prolonged 21 days and in the absence of details I should infer the concurrence of secondary 
fever or local complication ; in No. 4 it was prolonged to 13 days ; and in No. 6 to 19 
days, doubtless from similar re-isons : the author truly remarks ' it is striking how much 
the course of relapsing fever varies.' Previously, Dr. Claud Muirhead at Edinburgh, had 
noted the conjunction of ' typhus ' with relapsing fever, furnishing a chart which 
shows secondary fever coming on three days after the second relapse, in a youth of 17 
(patient No. 17) : £din. Med. Journ., vol. XVI., July 1870. Dr. Aufrecht, of Magdeburg, 
in a later account, describes a case of ' typhus ' coming on after fehris recurrens : it began 
three days after crisis, lasted thirteen days and ended with cystitis and pyelonephritis ; the 
whole resembhng secondary i ever with eventual complication : ' Pathologi^che Mittheilun- 
gen,' I Heft. 1881. These examples will suffice for ordinary illustration of views yet re- 
quiring definition ; and it is significant of the difficulties to be encountered m establishing 
these views and furnishing the means of precise diagnosis, that from St. Petersburg, where all 
typhus-like fevers have long been predominant and whence the recognition of their poss:ble 
admixture has chiefly come, only scanty evidence has yet been made available. Thus, of 
the five cases described by M. Borodulin, but one is supposed to represent mixed (j/^s/zKi 
recurre7is znA. exanthematicus : patient, a medical student, 24, admitted on 6th day of 
illness, with symptoms of invasion-attack, spirillum not seen ; sudden fall on 9th day, with 
an immediate rebound and six days of continuous pyrexia, high yet soon declining ; then 
a true relapse (spirilla seen), and most probably a second relapse ; eventual recovery. 
Here the main point concerns the first part of the illness, which is said to have come on 
gradually : the typhoid state speedily supervened and delirium lasting till 15th day or end 
of rebound ; there was a ' roseola exanthem.,' and no evident blood-poisoning ; these con- 
ditions are regarded as adverse to the view of the fever being spirillar ; whilst the crisis and 
sweats on the 9th day, and subsequent course of sickness are considered as adverse to the 
view of simple typhus. My studies at Bombay enable me to suggest with confidence that 
the instance is simply one of secondary fever after invasion of spirillar pyrexia, the absence 
of visible blood-contamination at first being doubtless accidental, for 1 have myself in a 
first examination sometimes overlooked the parasite ; there is nothing recorded to contra- 
dict this interpretation, which serves to explain the whole case. 



236 SPIRILLUM FEVER. 

is manifested by proneness to intermittent and remittent fever by the 
paroxysmal character of other fevers (e.g. the symptomatic), and by in- 
creased liability to visceral congestions and inflammations. It becomes, 
therefore, of interest to enquire if the late ' new ' fever seemed any way 
modified by malarious influence, or became associated with it. 

Careful perusal of the original descriptions of recent European ob- 
servers, has convinced me that Relapsing Fever has shown precisely the 
same features in Bombay as in non-malarious countries of the West, 
where its practically unchangeable character has long been admitted ; 
hence the inference that malaria had not considerably modified the 
disease, as seen in Western India, 

As to association of their specific causes, the similarity of the spirillar 
pyrexia to that of ' remittents,' the like tendency to periodical recurrence 
and to splenic implication as in 'agues,' and the preference for ma- 
larious districts said to be shown in some European countries by relaps- 
ing fever, are the chief points noted in favour of such association: they 
have little validity in the present connection. 

At Bombay the late epidemic fever was not coequal with the ma- 
larious, as regards either local distribution or local intensity, being far 
more restricted in its area, and not severest where common fever worst 
prevailed : it was frequent where malaria was not abundant, and also in 
non-malarious seasons of the year. 

I do not know that spirillum fever especially predisposed to, or re- 
excited, the malarious influence. 

Conjunction with Remittents. — These even less than typhus possess 
any pathognomonic characters, and during the pyrexial state it would not 
be possible to determine whether or not the two infections were con- 
current. During the usual apyretic periods, secondary fever arising 
might be equally undistinguishable in form : nor would the test of anti- 
periodic treatment suffice here, for the remittents of Bombay are highly 
stubborn. And, in brief, clear evidence of the simultaneous prevalence 
of the two fevers never presented itself ; but when it becomes possible 
to test malarious fever as infallibly as the spirillar, such evidence may be 
found. What is known, is that relapsing fever will pursue a regular 
course in a thoroughly malarious subject ; and also when succeeding 
closely to a typical malarious attack. 

Intermittents : Agues. — I have previously stated that single and 
repeated paroxysms of fever were not uncommon as third, or second, 
and occasionally as fiist relapses ; they were also seen as sequelse of 
spirillum fever, and in rare instances as rebounds of temperature after 
invasion and first relapse, or even preceding these attacks. As there are 
no means of distinguishing such last-named transient events, except by 
their association with the better known, discussion of their true cha- 
racter would be futile : the onus of proof that they are really aguishj 
would be on those who make this affirmation ; at present, I regard the 
phenomena as incidental attendants on the spirillar infection. 

It is right to add that a difference of opinion has obtained concerning 
the relationship of relapsing fever and intermittents, even amongst 
physicians residing in the same locality ; and until the means of more 
precise diagnosis become available, such difference seems likely to last. 



ICTERIC FEVER. 2375 

The conditions under which ague-Hke paroxysms occur in the body are 
very numerous, and include many non-malarious influences.' 

Icteric Fever, commonly Spirillar. Synonyms. — Yellow, icteric 
or bilious Relapsing fever ; Yellow fever (typhus icter'ddes) ; Bilious 
typhoid (bilioses typhoid) ; Typhus biliosus ; possibly some bilious Re- 
mittents of the East. 

An unusually fatal form of fever distinguished by deep jaundice, 
irregular pyrexia, early prostration and a tendency to localised inflam- 
mations, was noted early in the Bombay epidemic and continued to its 
close. So far as I know, it had not been seen of late years previously 
to 1877, and hence bore a distinct relation to conditions then arising. 
Most of the cases I saw were referable to the spirillar disease, constitut- 
ing a variety which merged by many gradations into the average forms 
of relapsing fever : there remained, however, a residuum of examples 
not displaying specific blood-contamination, and yet not to be separated, 
in a clinical sense, from the majority ; and these cases gradually passed 
towards the class of remittents, forming a kind of intermediate group of 
themselves. 

It is, I presume, because experience elsewhere (in Eastern or tropical 
areas, at least) was of similar character, that doubts have been expressed 
respecting the nature of ' bilioses typhoid ' (Greisinger) ; nor can I, also 
relying upon observation in a malaria-district, free myself wholly from 
such doubt. Taking the Bombay data as they stand, I have decided to 
include under the present heading some of the non-spirillar cases seen; 
they are commented on at the end, and it is to be remembered that all 
selection of cases for analysis has been made at personal discretion. 

The occurrence in Western India of genuine icteric relapsing fever 
forms a notable link in the chain of continuous data, establishing the 
identity of the late epidemic there with European epidemics. 

Though not absolutely the severest kind of fever seen, this icteric 
form was in aspect the most striking, and as such was certain to attract 
particular attention. Characteristic instances occurred in about 5 per 
cent, of all admissions ; amongst casualties the proportion would be 
15-20 p. c, according to individual judgment. 

Examples were noted at commencement of the epidemic, before 
microscopical aid to diagnosis was employed ; of 20 selected later ones, 
13 dated in 1877 (oftenest when hospital and city mortality were highest), 
5 in 1878 (also concurrent with most casualties), and 2 so late as 1880. 

Intense jaundice being invariable, it was generally accompanied by 
an eruption of red spots or petechiae ; appearing early at invasion-attack, 
beyond which most cases did not pass. At the relapse, however, jaundice 
might be most marked amongst casualties, or amongst survivors no 
longer present : it had no special relation of its own, nor were the severe 
symptoms conjoined with it peculiar to such combination. There was 
nothing to distinguish the form or duration of pyrexia during invasion ; 
only, as in bad cases generally, the history often pointed to persistence 
of fever longer than 7-8 days, and the mode of defervescence tended to 

' The somewhat discordant views of Niemeyer, Lebert and Litten on the connection 
of Ague (chiefly sequelar) with relapsing fever, need not be detailed here; since for its adjust- 
ment the whole subject has yet to be scrutinised by exact methods. Bombay was not a 
suitable locality for such investigation. 



238 SPIRILLUM FEVER. 

the lytic, a marked crisis not being seen in the worst examples : second- 
ary fever and local complications were as frequent as in other severe 
cases, tending, as usual, to efface the average features of their tempera- 
ture-charts. Rarely were the higher thermometric readings seen, viz. 
thrice only ; the max. t. being 106° F. at end of invasion ; commonly 
the pyrexia very moderately pronounced, and readings somewhat below 
the mean of all cases at same stage. 

The 20 patients were males, at early adult age : I do not recollect 
seeing any infant or very young, and rarely an aged person or female, 
deeply jaundiced. Most subjects were in an emaciated or cachectic con- 
dition ; yet not all, amongst recoveries especially. The typhoid state 
was present or imminent 14 times, and in nearly all the casualties: great 
depression of the system was invariable. 

Localised attendants were an eruption of vermilion-tinted spots, or 
of petechiae, common yet not in proportion to severity when other com- 
plications existed ; parotitis, hiccup, hepatitis, enteritis (2), dysentery ; 
pneumonia (4) pericarditis, epistaxis, cerebral haemorrhages (2) ; col- 
lapse. Minuter tissue-changes were also found, and in general death 
seemed referable to some manifest lesion, yet not invariably so. 

Diagnosis was made at a glance ; respecting assumed resemblance to 
yellow fever, I may remark that in the only two fatal cases known of copious 
gastric haemorrhage, jaundice was absent. Prognosis — the recoveries 
were 6 or possibly 7, and convalescence promised to be tardy : it is, 
however, certain that intense jaundice attended with eruption was con- 
sistent with comparatively mild specific pyrexia ; such favourable result 
being due to the absence of severe complication or accident. That 13 
or 14 deaths were known in 20 cases is significant, especially in connec- 
tion with ascertained lesions. 14 of the 20 displayed the blood-spirillum, 
and of these 5 survived. The following notes pertain to Case XXXII., 
summarily described in Chapter IV. as an instance of intercalated relapse. 

M., 35, admitted with his young son from a weaving factory, on estimated 8th day 
e. 1. 1 02°"2, of invasion, p. 128 ; the usual symptoms of spiriUum fever with much debility, 
haggard look, deep jaundice, great hepatic tenderness and bruising pains in the r. 
shoulder, tongue dry and shrunk, numerous purplish spots in the left infra-clavicular 
region, large, level, ineffaceable, of irregular form and clustered, others elsewhere 
and red patches on the back : the blood was full of spirilla. Next afternoon the per- 
turbatio critica, t. 104°, p. 120, crisis with sweats, and on loth day m. t. 98'^ '2, 
p. 96, much depression, jaundice more marked, has sore throat (much vascularity 
visible), and pain on deglutition, the eruption more abundant and manifest in the now 
pallid skin, and it merges into true petechia; : a rebound shortly followed, e. t. IOl°, 
p. 110, much depression, fresh spots now partly papular, hiccup (? similar sjiots in 
the stomach), nth day -has rallied a little, more skin spots and apparently others 
in the fauces and on tonsils, e. t. 100°, p. 112 : next day, still rallying, no new 
eru tion and the former spots are fading, e. t. 98°, p. 86. 13th day — improves, yet 
still pain on deglutition and aching of joints, the eruption fades quickly, some older 
spots having disappeared and the later become papular as if from oedema ; axillary 
glands not aff' cted, a slight e. rise of temperature without chills and increased aching 
r)f the loins. 14th day — most of the spots have subsided, a few smaller ones are new, 
jaundice nearly gone ; aching pains severe and a smart felirilc paroxysm ( e. t. 104°, 
Vs. 130, and spirilla in the bloo<l), slight chills preceded and copious sweats ensued ; 
this was an intercalated paroxysm, iiide Ciiart No. 10, Plate V. Next m. t. 98°, 
p. 88. l6th day— still some soreness of throat and a slight tenderness of r. parotid 
region, no redness of fauces ; he is pale and giddy, but eats well ; some doubtful fresh 
spots. Next day, improves, but sleep disturbed by his having to wait on his sick 
son. i8th day — m. t. 98'''S, p. 88, slightly feverish in tlie night and feels weak j 



ICTERIC FEVER. 239 

there are spirilla in the blood (specific incubation-period), and next day, the relapse 
suddenly came on, e. t. I04°*6, p. 120; renewed debility, no fresh eruption or jaun- 
dice, but severe pains and a haggard look ; smart fever lasted 3 days and ended by 
crisis, some minute haemorrhagic spots then appearing on each side of the sternum : 
gastric irritability and splenic tenderness, weakness, yet soon appetite and as quick 
rallying as in his son (who was not jaundiced and showed only slight traces of an 
eruption). Previously I had not known such favourable ending of so unpromising a 
case, but here no complication had persisted and the constitution seemed fair. In 
another instance — M., 30, the first aspect was also unfavourable, jaundice and pallor 
being marked, petechise present and the debility great, there was epistaxis, too, at 
the fall ; yet in the absence of local lesion, rallying was prompt after the brief relapse 
which ensued. 

The 9 fatal cases formed a striking series : chart of" I is copied in PI. VI., No. 
25, being that of a man, 30, dying of pneumonia three days after apparent first crisis 
(' bilious pneumonia '), fever of remittent type, pulse moderately quick, jaundice deep, 
two petechial spots, the typhoid state and delirium, great enlargement of the liver 
with thin black stools, prolapsus ani ; even here slight rallying after cessation of 
specific fever was indicated, but the exhaustion proved insuperable, pneumonic symp- 
toms being latent. After death the hft lung was found inflamed, the spleen and 
liver very large, gall-bladder empty, kidnies (like liver) pale, ? fatty: the brain firm. 
A second case is No. LXXVIIL, the man dying of pericarditis and haemorrhages at 
close of first relapse ; and another instance of decease at this date, was seen in a man, 
30, admitted in a state of great debility at close of invasion, with rebound ; yet rally- 
ing and promising convalescence when the relapse set in, this proved to be prolonged 
and pronounced, and death occurred without fall of temperature ; both spleen and liver 
were found greatly enlarged. In a later case the patient showed but slight fever on 
admission (t. 99 '•2), and overlooking the rapid pulse (140) and quick breathing (48), 
together with the peculiar dyspnoea and abdominal di-teneion, I deferred close scrutiny 
till next day, when death ensued ; the blood was full of spirilla and proved to be so 
infective that two young men engaged at the autopsy caught spirillum fever, one 
dying.' In this example with other characteristic changes, there was found enteritis 
(diphtheritic): vide Case LXXXIV. for details : jaundice was also present in another 
instance of this kind, though not so deep as here and hence I have not included 
the example in the present list. The clinical charts belonging to this series, offer no 
peculiarity for notice. 

Six of the cases did not show the spirillum, and as a sample of local 
experience I subjoin a brief analysis of them. 

1. One not admitted till the 12th day, or after probable subsidence of specific 
fever ; the typhoid state present, and speedy death from pneumonia (max. t. 102'^) : 
the brother, ill for 6 days only, admitted at same time from same house (others were 
ill there), showed the spirillum and recovered ; he, too, was deeply jaundiced and had 
abscesses after crisis (1877). 

2. One admitted on 15th day, in typhoid condition, also had pneumonia and was 
removed by friends in a moribund state : max. t. 103°: judging from the whole cir- 
cumstances of the case, this, too, was an instance originally of specific infection. 

3. Admitted on reputed 5th day of illness, with all the aspect of a patient at the 
critical fall of spirillum fcver : depression great, rallying slow, and a kind of long,' 
low relapse followed ; then fever of more intermittent type, increasing cachexia and 
fatal exhaustion ; no autopsy. As the fresh blood upon several occasions failed to show 
visible contamination (improved method of scrutiny then unknown), the true nature 
of the case remains unproven ; but a neighbour was admitted with spirillum fever 
about ihe same time, and there was no moral doubt as to the specificity of illness. 

4. Admitted on reputed 5th day, t. 103°, subsequent pyrexia res.mbling that of 
remittent fever, subsidence gradual to normal after 10 days ; during this time paro- 
titis and epistaxis, which at this epoch were practically unknown in Bombay, except 

1 These accidents at Bombay affordfd proof of the specific character of ' bilious 
typhoid,' parallel to the deliberate inoculation successfully practised in Russia, which is 
usually quoted by continental authors as evidence of the ' recurrent ' nature of this form 
of spirillum fever. In neither of my hospital assistants \V3.% jaundice a m: r_;ed symptom : 
for details see Chapter on Contagion. 



240 SPIRILLUM FEVER. 

in connection with the new fever : the man was unconscious on admission, abdomen 
distended and tender in both hypochondria, hver and spleen found to be enlarged : 
patient an immigrant from the famine-districts ; the fresh blood was repeatedly ex- 
amined with negative results, this happening in all forms of secondary fever. 

5. Admitted without a history, in state of collapse, was said to have come from 
the Deccan a few daj^s .previously : the symptoms included intense debility, restless- 
ness, not real stupor, eyes bright though injected ; an eruption of ineffaceable pink 
spots ; pupils contracted ; the typhoid state imminent : rallying slight, the liver was 
implicated, soreness of the skin, much irritability of the muscular tissue, no stool for 
three days. In a few days fatal exhaustion, and at the autopsy double pneumonia ; 
the liver contained a small abscess, seemingly old ; spleen reported shrunken and dry, 
its weight 3 ozs., kidnies probably not diseased, sub-mucous hasmorrhagic spots in 
stomach and at end of ileum, with congestive patches elsewhere. Blood-poisoning was 
indicated, its source untraced. I have known similar results attend spirillar infection. 

6. Admission on reputed 6th day of illness, t. 102° -4, p. 96, fever continued for 
seven days, being moderately sustained ; blood examined twice with negative results : 
patient low and delirious, urine retained, increase of jaundice, liver-dullness les- 
sened (?), the splenic increased, abdomen tympanitic, respirations slow, pupils con- 
tracted ; the breath ammoniacal ; coma supervened. At autopsy, the liver weighed 
2 lbs. only, yet seemed healthy, the hepatic cells being reported unchanged : spleen 
enlarged, kidnies congested, cerebral congestion with eflusion of serum : patient a 
police constable exposed to malaria, and other infection. 

Regarding the above, such cases had not been seen of late in 
Bombay, and their symptoms and history, when not suggesting a prior 
relationship to spirillar irjfection, were seldom inconsistent with such 
relation : instances like the two last of pyaemia (?) and cholaemia (?) may 
have had a different connection, but too little of the illness was seen to 
warrant a decided opinion as to their original character. I have termed 
this group of cases ' Icteric Fever,' because not in all was the blood- 
spirillum seen, and hence proof positive of their specific nature is want- 
ing ; but my opinion is that 4 of the 6 last non-spirillar cases really 
belonged to the same specific disease as the earlier ones, and that the 
remaining 2 of the 6 are examples of lesion consecutive to fever. There 
is nothing here to gainsay the extreme probability that typhus biliosus 
was the same disease in Bombay, as it is in Europe. 



241 



CHAPTER VIII. 

MORTALITY OF SPIRILLUM FEVER. 



GENERAL FEATURES — I. DEATH-RATE. 2. DATE OF DEATH. 3. AP- 
PARENT CAUSE. 4. MODE. DETAILED FEATURES 5. INFLUENCE 

OF SEX. 6. AGE. 7. SEASON. 8, PERIOD OF EPIDEMIC. 9. SOCIAL 
STATION. 10. BIRTHPLACE. II. RACE. T2. HABITS. 13. PREVIOUS 
DISEASE. 14. MENTAL DEPRESSION. 1 5. BODILY EXHAUSTION. 

I. Death-rate. — Of 6x6 demonstrated cases in died, the rate of 
decease amounting to 18*02 per cent; Amongst ordinary hospital 
patients the greatest mortality was noted at the J. J. Hospital, where 
there were 82 deaths in 453 admissions (equal to i8t p. c.) ; whilst at 
the G. T. Hospital, the deaths were 11 in 94 admissions (or 117 p. c). 
Amongst the known instances of disease acquired by contagion at both 
hospitals, the deaths were 18 in 69 cases, or at the rate of 26-i p. c. 
The proportion of deaths from famine-fever occurring at the Camp of 
Refuge, 1877, was not ascertained. 

When compared with the statistics of most hospitals in European 
countries {e.g. 403 per cent, in British hospitals, 4*3 to 7*2 at Breslau, 
though as high as i4'97 p. c. at St. Petersburg in 1865), the above data 
will serve to show how severe was the late epidemic at Bombay ; nor is 
this feature annulled by the circumstance that an unusually large pro- 
portion of ordinary admissions happened at advanced stages of illness, 
or by the fact of acquired disease amongst those already sick being un- 
commonly severe : for the first is a common condition, and the second 
may not be peculiar to Bombay : see the Memorandum below. Details 
are the following. 

TABLE XII. ~Death-k AXES aT BombaV. 



Hospital 


Subjects 


Survived 


Died 


Total 


Death-rate 1 
per cent. 

i8-i 

30-3 


J. J. H. 
G. T. H. 


Admissions 
Contagions all : — 

r Patients . . 
\ Servants 
(Pupils . . . 

Admission'? 
Contagions all : — 

( Patients . . 

\ Servants 

i Pupils . . . 


371 

39 


82 

17 


453 
S6 


20 

9 
10 


10 
6 
I 


30 
15 
II 


33-3 
40- 

9- 


83 
12 


II 
I 


94 
13 

I 
6 
6 


117 

7-6 


I 
6 
5 


I 


o- 
o- 

i6-6 



242 SPIRILLUM FEVER. 

2. Date of Death. — Analysis of the 99 deaths occurring at the 
larger hospital, after excluding 7 examples of uncertain date (though 
most probably near termination of first attack), furnished the following 
results. 

a. Invasion-attack. — 48 deaths (or rather more than one-half) took 
place at this stage ; viz., on estimated fourth day 3, fifth day 4, sixth 
day 3, at or about apparent acme of fever 27, and at stage of defer- 
vescence II. Respecting deaths at the earlier of these periods, it is 
possible some belonged rather to the acme of short attacks, for events 
so much abbreviated were distinctly noted ; and hence it might be 
assumed that f of all casualties at this stage took place at or near the 
culminating point of illness, when the patient's strength is often severely 
tested, and when always the blood seems to undergo a rapid change of 
visible condition. Deaths at the decline of fever chiefly belonged to 
the rarer form of gradual, or lysis-like defervescence. 

b. First Interval, or Period after specific pyrexia. — 24 deaths, or 
about \ of the whole series : thus, there were three casualties on the 
first day after crisis, i on the second, 4 on the third, and 2 on each of 
the succeeding three days ; the numbers subsequently being scattered 
over dates ranging 1-2 months, and pertaining rather to sequelar 
phenomena. It is, therefore, either immediately after the first crisis, or 
within about a week later, that one-half the deaths at this epoch may 
be expected to occur, 

c. First Relapse. — 6 deaths, or about ^-^ of the whole : possibly 
this diminished proportion of casualties at first relapse is excessively 
small, from some patients overlooking the earlier attack ; yet there is 
other valid evidence of a common mitigation of symptoms, upon fresh or 
auto- inoculation of the system. Deaths occurred after the third day, 
and as then the acme of attack is always contingent, it may be said 
that they tend to happen (as during the Invasion) in connection with 
this culminating epoch. 

d. Second Interval. — 11 deaths, which occurred chiefly from 2 to 8 
days after crisis ; the remainder being distributed over periods reaching 
to the 1 8th day. 

e. Second Relapse.- — There was only i instance referable to the 
third day of illness ; and, as in most late casualties, local inflammation 
was present. 

/ Sequelar periods. — 2 patients died in hospital, at 30 and 42 days 
after cessation of specific pyrexia : whether or not others after leaving 
hospital, failed to recover, is unknown ; but occasionally the state of 
the sick impatiently insisting upon their discharge, was unfavourable 
to life. 

Analysis of the 12 casualties occurring at the G. T. Hospital, 
furnishes results which may be estimated as follows : — 4 deaths during 
first attack (all with temperatures little raised) ; 5 during first interval, 
2 happening immediately after first defervescence ; 2 deaths at or near 
close of first relapse ; i very shortly after the second crisis. 

The hour of the day when death was recorded varied indefinitely, 
but most frequently it was from midnight to 6 a.m., and next 
oftenest from noon to 6 p.m., which are the usual periods of 
decline and rise of body-heat respectively : further inference was not 
practicable here. 



MORTALITY— SEX. 243 

3. Apparent Cause of Death. — In by far the majority of cases, life 
seemed to be destroyed by febrile distress or consequent exhaustion, 
such being the conclusion arrived at in 63 of 99 casualties : cerebral 
haemorrhage was ascertained 7 times and may have been rather more 
frequent : 2 deaths arose from copious gastric haemorrhage and i from 
femoral thrombus : 17 were attributable to pneumonitis, and milder 
degrees of this complication may have been overlooked : there was 
acute dysentery 8 times, and once hepatic abscess. The remarkable 
state here termed 'febrile stress,' consisted in exaggeration or acute 
modification of the severer symptoms elsewhere described as occurring 
at the close of attack during Acnle, at initiation of Crisis and in course 
of Lysis defervescence : the circulatory and respiratory organs being 
most obviously affected, as well as the viscera contained in the upper 
abdominal zone. In characteristic instances this distress came on more 
or less suddenly, and was of brief duration ; when not proving fatal, it 
was followed by prompt and complete recovery, and from personal 
experience I know how great is the suffering at culmination of the 
febrile periods, before the advent of delirium and unconsciousness. 
Hence, upon wide grounds I gained the impression that were critical 
epochs prolonged, even slightly, the mortality from spirillum fever 
would be much greater than it actually is. 

Under the head of exhaustion, should be included the state of 
collapse in which febrile crisis may terminate. Possibly my observations 
were defective, but it happens that death in the condition of extreme 
depression was most rarely indicated ; and however pronounced, this 
state did not appear in itself to be one of peril, patients (contrary to 
first anticipations) rallying from it surprisingly well. There is also a 
fatal form of debility, sequelar in its advent. 

The symptoms attendant upon ordinary local lesions, need no further 
allusion here. In general, inferences formed during the later hours 
of life were confirmed at the autopsies, which were practised in upwards 
of three-fourths of all casualties. Whether or hot superadded blood- 
contamination (e.g. pyaemic or other auto-genetic kind) might be more 
frequent than appeared, I will afterwards enquire. Sect. III. Chap. III. 

4. Mode of Death. — Whilst the blood-poisoning usually tetminated 
in insensibility, often, prior to the end, there were signs of stupor or 
coma ; and at close of the febrile attacks, especially, cerebral haemor- 
rhage in varying degree, might be regarded as a likely contingency. 
How far, in addition, the sympathetic ganglionic centres in the abdomen 
became implicated, and by their derangement contributed to the fatal 
suffering, can as yet be but indefinitely surmised. 

It was sometimes apparent that death began at the lungs with active 
congestion or inflairimation, as primary phenomena : at other times, 
derangement of the breathing was but part of more general disturbance. 

Death of cardiac origin was ftot rarely indicated by the frequent and 
feeble action of the heart, without signs of other lesion than concurrent 
derangement of the breathing, and marked fulness and tenderness of 
the abdomen. 

5. Infiiience of Sex. — Of the total deaths 71 '77 per cent, were males, 
and 28-83 P- c. were ferrjales : as amongst total survivors the proportion 
of females was only 15 "32 p. c, it would appear that this sex suffered 



244 



SPIRILLUM FEVER. 



more severely than males from famine-fever, and I may observe that 
the only 2 ward nurses attacked in the J. J. Hospital died at invasion, 
and as well 3 out of 8 female sick seized in the same hospital, of all 
ages. The excess of female deaths was noted under the age of 15 
(particularly from 6-10), and again after 36 years ; whilst during the 
intermediate periods, and especially at the epoch of greatest total 
mortality — viz. 26-30, the proportion of females dying was less than 
that of males. 

6. Age. — The influence of age was apparent, in the greater com- 
parative mortality at both extremes of the scale of years : thus the 
general mean death-rate being about 18 p. c, the rate was 27 p. c. up to 
the age of 10 years, and then in the two succeeding decennia declining to 
II p. c (11-20 years) and 16 p. c. (21-30 years), it rose with ad- 
vancing age above the mean to 24*5 p. c. (31-40 years), 294 p. c. 
(41-50 years'* and 37*5 p. c. (51-60 years). The material for these cal- 
culations is contained in the appended Table XTII. 

TABLE XIII. — Age and Sex in Spirillum Fever. 



Age 
in years 


Survivors 


Dying 


Grand Totals 


M. 


F. 


Tot. 


M. 

2 

2 
2 
6 

14 
24 
12 

6 

6 

I 
4 


F. 


Tot. 


M. 


F. 1 Tot. 


To I 

2- 5 
6-10 
11-15 
16-20 
21-25 
26-30 

31-35 
36-40 

41-45 
46-50 

51-55 
56-60 


2 

7 

25 

65 

105 

116 

35 
28 

7 
12 

3 
4 


I 

6 
13 

4 

4 
10 

14 

f^ 

2 

3 

3 


I 

8 
20 
29 
69 

"5 

130 

40 

37 

9 

15 

3 

7 


I 
6 
I 
3 
5 
4 
3 
4 
I 

3 

I 


2 
I 

8 

3 

9 

19 

28 

15 

10 

I 

9 
2 

4 


2 
2 

9 

27 

71 
119 
140 

47 

34 

7 

18 

4 
8 


I 

7 

19 
5 
7 

15 
18 
8 
13 
3 
6 
I 
3 


3 
9 

28 
32 
78 
134 
158 
55 
47 
10 

2\ 

5 
II 


Totals . . 


409 74 


483 


79 


32 


III 


488 106 


594 



As the late epidemic at Bombay was mainly due to an influx of 
persons either sick or mo.st readily falling ill, useful comparison of the 
above data with Age and Sex of normal population, or ordinary mortality 
in the town, cannot be made : nor could the total immigration data be 
accurately estimated. Respecting comparison with experience of 
famine-fever in Europe, T note that besides a high general death-rate, 
the considerable mortality in early life at Bombay seems peculiar ; 
whilst afterwards there is an accordance in the progressive augmentation 
of mortality according to age. 

7. Season of the Year. — There was no distinct evidence that during 
the heavy rains at Bombay, or in the succeeding more malarious months, 
ccpJeris paribus, \\\& death-rate was considerably or uniformly altered ; 
and from local knowledge I should infer that a seasonal influence, if 
present, must have been quite subordinate. 



MORTALITY — PREVIOUS DISEASE. 245 

During the two chief years of sickness the larger hospital mortality 
was 20 per cent, of admissions in both hot and wet seasons, and about 
14 p. c. in the cold season (data then fewer and imperfect) ; during the 
year 1879, the 8 deaths noted at my smaller hospital mostly occurred in 
the rains and cold season. Temperature ranges on Bombay island are 
probably too narrow alone to influence the course of a contagious 
malady, and owing (as would seem) to purely contingent circumstances 
of race and general condition, the death-rate of famine-fever during the 
rainy months varied from 18 p. c. in 1877 to 25 p. c. in 1878. 

8. Period of Epidemic — ^txe, too, the disturbing influences w^ere 
too considerable to permit of adequate estimate of mortality at beginning, 
middle and end of the epidemic ; but so far as appears, the mere in- 
tensity of infection (epidemic influence) may not have greatly varied 
throughout. During 1877 the death-rate of the J. J. Hospital was 18 
p. c, and in the following year it was 21 '2 p. c. although the public 
sickness had become much less : in 1879 at the smaller hospital it was 
only 15 p. c. of admissions, yet I know that the infective virulence of 
the disease was still great, at this late date. 

9. Station in Life. — With rare exceptions, the deaths occurred 
amongst the poorest classes of patients admitted ; town residents sup- 
plied a few petty traders to the list of casualties, but the well-to-do 
sections of the native community, were conspicuous by their absence 
here. I heard, howevej-, of isolated fatal cases amongst merchants out- 
side hospital ; and the fact of several well-nourished hospital servants, 
and a few well-fed and well -lodged medical subordinates dying of the 
infection, sufficiently shows that, in detail, social status may have little 
essential influence on mortality. 

10. Birthplace and Residence. — In the chapters on History of the 
Epidemic and on Contagion it is stated that the town-residents of 
Bombay, most of whom were born in the Mofussil, displayed nearly as 
high a mortality-rate as the immigrants themselves ; and this circum- 
stance indicates the comparatively little effect on death-rate of slighter 
differences in personal states, when the conditions of infection and insani- 
tation generally were favourable to flourishing of disease. 

11. Race. — I have elsewhere pointed out some differences in the 
death-rate amongst the two principal races of Hindoos and Mussulmans, 
the indications being that the less robust weaver class from N. India 
suffered rather the most. The out-caste sections of the community, also, 
were excessively implicated. So far as race and caste represent diffe- 
rences of diet (and such differences are not considerable in Western 
India), virulence of the new fever did not, per se, appear to be essentially 
influenced thereby. 

12. Injui-ious Habits. — The constant use of intoxicating drugs was 
too rare amongst the poorer classes to attract attention, and only in a 
few particular instances did it seem that prior intemperance led to an 
unfavourable issue of illness. 

1 3. Previous Disease. — So far as appeared to me, the attacks of famine- 
fever were not necessarily rendered more fatal by the circumstance of 
pre-existing malarious cachexia ; such impairment of health, in its 
several degrees, was doubtless widespread throughout the community, 
and might be difficult of detection in fever patient! seen for the first 



246 SPIRILLUM FEVER. 

time, yet I was not impressed with the evidence of its particularly 
hurtful influence, except in some extremer cases. The large mortality 
amongst patients in the J. J. Hospital who became infected by con- 
tagion, would at first sight indicate the baneful influence of previous 
disease, yet the death-rate amongst healthy hospital servants at the 
same institution, was nearly as large ; and if (as is not improbable) the 
constant or frequent breathing of impure or tainted air had a bad effect, 
still I note that of 9 lads acting as clinical clerks in the medical wards, 
w^ho became infected, not one died or came near to death during the 
worst year. 

1 4. Mental Apathy and Depression. — This state was common amongst 
hospital patients, and may have aggravated the enfeebling effects of 
infection ; in a few instances its effects were marked. 

15. Bodily Want and Exhaustion. — Unquestionably the injurious 
consequences of fatigue and jDrivation, were not less marked at Bombay 
than is recorded of European cities ; yet whilst the whole history of the 
epidemic under notice, tends to show that spirillum fever prevailed 
most (if not first) and most severely, amongst the famine-immigrants 
flocking townwards, yet it was also appf^rent that not all such immigrants 
were either starving or exhausted (for many travelled by rail and had 
some means, or could work) \ and, as matter of fact, only a certain pro- 
portion of the dying in hospital, whether new-comers or residents, were 
in a state of actual emaciation upon admission. It is possible that 
debility of the frame was often concerned with the marked tendency 
seen to death from exhaustion, at acme of the febrile attacks ; still 
exceptions to' this view were not very rare, and at last I came to refer 
casualties to either unusual degrees or qualities of infection, or else 
varying personal predispositions : both of these influences, however, 
being presumptive only, and neither of them opgn to close investi- 
gation. 

Memorandum on the Mortality of Relapsing Fever in Europe 
OF late years. — From a brief review of some recent writings, I find 
European experience to have differed somewhat from that at Bombay. 

Death-rate. — In my estimates, no distinction was made between the 
ordinary form a.nd the severer type of relapsing fevet known as bilious 
typhus^ because it did not seem to me to be required ; but in the St. 
Petersburg epidemic of 1865, such distinction was marked by Dr. H. 
Zorn (' Petersb. Zeitschrift,' vol. IX. 1865), who states that the death-rate 
of the common form was 9 '69 per cent, whilst that of the bilious form 
was 46 '34 p.c. Admitting this discrimination (which may be serviceable 
in India), it becomes obvious that the death-rate of an epidemic will be 
high or low, according to the proportion met with of the severer type ; 
and in the course of the same epidemic, it will also vary accordingly. 
The bilious type has not beeri common in Great Britain, nor in recent 
German epidemics ; and casualties attended with deep jaundice were 
not numerous at Bombay, but it is quite possible in other parts of India 
experience has been different, 

Date nf Death — In no European records met with is the proportion 



MORTALITY — RATES. 



247 



of deaths at invasion and first interval, nearly so large as that above 
stated for Bombay. Thus, of 129 casualties enumerated by Drs. 
Murchison (England), Zorn (St. Petersburg), and Litten (Breslau), only 
13 or about 10 per cent, occurred at the invasion-attack of fever ; but 
about 30 p. c. at first relapse, and 17 p. c. at late or sequelar periods of 
illness. Deaths during the first and second intervals were 16*2 p. c. and 
217 p. c. respectively. These ratios greatly differ from those I have 
named above, and it is not easy to account for this difference. It is, 
however, to be noted that Dr. Zorn distinguishing instances of bilious 
typhus, found that in this form the mortality was not only higher but 
more prompt, than in ordinary cases of relapsing fever ; thus of 36 
casualties 30*5 p. c. took place at invasion, nearly 20 p. c. at the first 
interval, and 30*5 p. c. at first relapse. All the figures are as 
follows : — 



TABLE XIV.— Dates of Death in Relapsing Fever. 



Dates 


Inv. 


I Int. 


iRel. 
37 


a Int. 


2Rel. 


Later 


Total 


Common form, Europe 


13 
II 


21 


28 


8 


22 


129 


Bilious typhus, Europe 


7 


II 


2 


— 


5 ! 


36 


Bombay experience 


52 


29 


8 


12 


I 


2 1 


104 



This datum is a very significant one for the sanitary history of India, 
I have not access to documents permitting of comparison of the late 
Bombay results, with those met with in casualties from the contagious 
fevers of N. Indian districts and large gaols during recent years ; but 
such collation must prove instructive, and it may be Indian experience 
has its own special features. 

Causes of Death. — So far as ascertained, there is here a close simi- 
larity of results between St. Petersburg and Bombay ; for in both cities 
upwards of 60 per cent, of all casualties have been attributed, in general 
terms, to febrile distress or exhaustion, whilst at Breslau (1872-3) only 
about 15 p. c. On the other hand, deaths from pneumonia or other 
lung implication were only 9 p. c. at St. Petersburg, but about 18 p. c. 
at Bombay, and about 80 p. c. at Breslau. This datum shows that in 
severe epidemics like the first two named, death tends to occur from the 
fever itself ; in the milder outbreaks from complications, chiefly of the 
lung. A preponderating cause at Bombay, was cerebral haemorrhage since 
Dr. Zorn does not allude to it ; but another contemporary observer 
(Dr. Kremiansky') expressly names haemorrhagic meningitis as a frequent 
cause of death m St. Petersburg, and Dr. Lebert has adopted this 
opinion. The summary of these analyses is that in India relapsing 
fever was uncommonly severe, early causing death and that mainly from 
the fever itself ; without there being seen, at all frequently, the deep 
jaundiced type known as 'bilious typhoid.' It is necessary to add that 
my examples were all of demonstrated spirillum fever, whilst those of 
Drs. Zorn and Kremiansky were not diagnosed by blood-scrutiny. 



248 SPIRILLUM FEVER. 



CHAPTER IX. 

ANATOMICAL LESIONS. 

INTRODUCTORY OBSERVATIONS. SUMMARY. DESCRIPTION OF LESIONS. 
LESIONS ACCORDING TO STAGE OF FEVER : FINAL REMARKS, 
MEMORANDUM ON EUROPEAN OBSERVATIONS. 

Materials were derived from the two Native General Hospitals during 
the years 1877-8-9. A few records have been mislaid, but I know they 
were not peculiar : no selection of cases was made. Here only instances 
are employed, which during life were demonstrated by examination of 
the blood, to belong to the spirillum -fever series. Several other data were 
available of cases more or less presumptively of the same nature, which 
may be said in great measure to correspond to the data (}uoted in works 
of authority published prior to 1873, but such are not included and sel- 
dom referred to below ; no peculiar lesion was found amongst them. 
Of the J. J. Hospital records 64, of the G. T. Hospital 10, in all 74 ex- 
amples are now analysed : they pertain to classes of patients represent- 
ing in proportion of sexes, mean age, ratios of race, caste and occupation, 
residence and home, the bulk of famine-fever patients. Autopsies were 
most numerous at times when sickness was greatest : 48 of them were 
made at an interval of under 6 hours after death, and only 7 after a period 
of 1 2 hours : twice only was there any sign of incipient decomposition 
of the bodies. 

Medical officers in charge of the sick entered the details, stating in 
customary terms the aspects, and commonly the weight, of each organ ; 
all notes are preserved : at the great majority of autopsies I was present. 
Special scrutiny of the fresh tissues was made when practicable, and 
some parts are preserved. 

I have added a memorandum on the post-mortem appearances of 
inoculated monkeys, dying or killed at various stages of specific fever. 

Below, the morbid lesions are first summarised, then described in 
anatomical order, and finally considered with reference to the stage of 
fever at which they were found. Histological memoranda are appended ; 
from my last specific illness ending with ophthalmitis, they are but few. 
Some repetition of the data was inevitable in the course of these 
analyses ; to supplement deficiencies, some brief notes copied from pub- 
lished European sources are subjoined, and these will serve the 
additional purpose of aiding in the identification of spirillum fever as 
seen in India and Europe. Minute description of the Blood is relegated 
to the Section on Pathology, Chapter I. 



ANATOMICAL LESIONS, 249 

I. SUMMARY, 

Emaciation was rarely extreme. Vibices and spots on the skin were 
never prominent. The aspect of the Blood was in no respect peculiar, 
nor was it uniform. Unusual deliquescence, with staining of the endo- 
cardium and inner coat of blood-vessels, was very rarely noted. 

Rigor mortis. — At invasion-stage rigidity had not set in so early as 
I hour after death, and seldam under 2 hours ; it was most marked be- 
tween 6 and 8 hours, and sometimes then commencing to disappear ; at 
10 hours, it had generally subsided, or much earlier in emaciated sub- 
jects, but exceptionally lasted till 12 or even 16 hours; it was present 
when the body still retained warmth and the blood was fluid ; and had 
sometimes passed off while fluidity remained : it has been noted when 
a certain amount of decomposition had begun, 16 hours after death as 
the critical fall of fever. It began rather later {i.e. after 2 hours) and 
lasted longer {e.g. 13 hours), in subjects dying during the first apyretic 
interval. In, death during first relapse, it had come on so soon as i 
hour after death (body well nourished). At the second apyretic inter- 
val its advent was somewhat longer delayed. There did not appear, 
however, any absolutely fixed relation between the onset of post-mortem 
rigidity, and the febrile or general state of the subject during life. The 
presence of even deep jaundice, seemed not to influence this phe- 
nomenon. 

The aspect of the voluntary muscles, so far as exposed to view, 
rarely struck me as being peculiar ; nor was their consistence markedly 
abnormal. Subcutaneous and deeper-seated extravasations of blood, or 
■ collections of serum, and changes in adipose or fibrous tissues were 
extremely rare. Some degree of bilious staining of the tissues was not 
unusual, and in the more jaundiced cases pronounced. 

. Main aspect of organs ; one or more changes may co- exist. 

Brain: 57 inspections. A quasi-normal aspect in 3, congestions, 
inflammation of meninges 3, haemorrhage chiefly meningeal 10, sub- 
arachnoid effusion of serum 23, pallor 9, an old clot once. 

Lungs : 74 inspections. Quasi-normal 10, pale and collapsed 21, 
congested 13, consolidation chiefly pneumonic 21, subserous petechias 4, 
bronchitis old and recent 2, pleurisy old and recent 3. 

Heart : 74 inspections. No apparent change 7, clots in right cavities 
47, substance decidedly pale 10, pericarditis i, subserous petechise 5, 
valvular disease (old) 3, fluid blood i. 

Liver : 74 inspections. Quasi-normal 4, enlarged (congested or pale) 
36, congestion 12, pallor 11, mottling 6, softening 2, abscess (old) 2, 
cirrhosis i. 

Spleen : 74 inspections. Quasi-normal 6, enlargement 46, infarcts 
14, softening 8. 

Kidnies : 74 inspections. Quasi-normal 10, enlarged 8, congested 
24, pallid 27, subcapsular petechise 3, granular (old) 2. 

Intestinal canal. — Stomach : 1 7 inspections ; pallor of mucous mem- 
brane 5, congestion, hsemorrhagic spots or ulcer 12, Duodenum : 34 
inspections; pallor or no change 21, congestion or petechise 13. 
Jejunum : 37 inspections ; pallor or no change 21, congestion or 
spots 16, Ileum : 42 inspections ; pallor or no change 21, congestions 



2 50 SPIRILLUM FEVER. 

inflammations or petechise 21. Caecum: 32 inspections ; no change 17, 
spots or ulcers 15. Colon : 36 inspections ; pallor or no change 21, 
congestion, spots or ulcers 15. Rectum : 31 inspections ; no change 
23, congestion, spots or ulcers 8. 

From this general view, it appears that there is no invariable lesion 
of the coarser kind to be found after death from spirillum fever : the 
term quasi-normal does not here exclude minuter change, and most 
probably the number of limited congestions or haemorrhages is un- 
derstated. 

As contrasted with a nearly equal number of contemporary autopsies 
made after death from remittent fever (so called), the special features of 
relapsing fever may be said to be cerebral haemorrhage, collapse of the 
lungs (pneumonia being about as frequent, viz. in near 33 per cent, of 
all necropsies), enlargement and pallor of the liver, enlargement or firm- 
ness and infarcts of the spleen, enlargement and pallor of the kidnies, 
congestion and extravasations in the walls of the intestinal canal. 

Coarse changes noted in monkeys dying of specific fever after in- 
oculation with spirillar blood, were the following — liver congested and 
once enlarged ; spleen large and congested ; kidnies healthy-looking : 
mucous membrane of stomach once unchanged, twice inflamed about 
the middle. In two animals dying on third day, the small intestines 
were inflamed throughout, beginning abruptly at the pylorus and ending 
at the ileo-caecal valve ; there being haemorrhagic spots also. Petechiae 
were seen twice on the lungs and on the heart ; the brain pallid only. 
Splenic infarcts were never noted, or pneumonia ; and I acquired the 
impression that the many morbid lesions of spirillum fever in man, 
might be due partly to inherent or acquired weakness of the tissues. 

2. DESCRIPTION OF THE LESIONS. 

The Nervous System.— In the absence of symptoms referable to the 
spinal cord, this large centre was but rarely examined ; it then seemed 
to be healthy. The sympathetic system, too, was only casually inspected. 

I. T/ie Brain. — The normal mean weight of the brain in Natives of 
Western India, has not been ascertained ; probably it is similar to that 
of indigenous inhabitants elsewhere, viz. somewhat over 40 ozs. in males, 
and somewhat under in females. Pathological weights would, I think, 
fall within normal ranges. 

External parts of the head. — The scalp was usually congested, es- 
pecially at the occiput ; the cranial vault and dura-mater with its serous 
lining, were very rarely altered in aspect ; the venous sinuses were com- 
monly filled and sometimes engorged. The outer membranes and 
adjoining surface of the cerebrum, were almost exclusively the seat of 
the morbid changes ; thus, in the arachnoid cavity and subarachnoid 
space more or less copious haemorrhages, commonest over the upper 
convexity of the hemispheres, and in the pia-mater here congestion and 
serous effusion. Rarely had the deeper-seated substance of the brain, 
either grey or while, undergone visible changes : the ventricles were not 
distended and their vascular appendages were either pale or but 
moderately congested. Inflammation of the brain or membranes, is rare 
in spirillum fever. 



ANATOMICAL LESIONS — BRAIN. 25 t 

The 3 instances in which the brain offered no apparent change, show 
that this organ may escape altogether, and they join on to the next series 
of simple vascular repletions : 2 deaths occurred in a febrile stage, i in 
the sequelar. 

The conditions of the cerebral circulation, and the facility with which 
serous transudation takes place from the distended and bare veins of 
the pia-mater and subarachnoid spaces, will account for the commoner 
appearances here seen ; and I should add that at least 64 p. c. of the 
deaths occurred during a febrile state of the system. Decided surface 
congestion was, however, sometimes present in autopsies of those dying 
during an apyretic interval, e.g. when pneumonia co-existed. Oc- 
casionally the blood was fluid enough to flow out of the vessels when 
first the chest was opened, and hence the degree of their impletion may 
have been underestimated. The significance of vascular turgescence, 
with or without attendant serous exudation, is not always alike. Cerebral 
congestion was either limited to, or most prominent at, the vertex : 
where, too, alone inflammation was seen, and haemorrhage was most 
frequent : it seemed almost always of passive (venous) character and 
was seldom pronounced or proportionate in the substance of the brain 
{piinda few and tardy) : usually serous effusion co-existed, and repletion 
commonly persisted after haemorrhages. The degree of turgescence 
varied much, and when considerable the accompanying serosity had a 
more or less reddish tint. 

There were two or three instances of active congestion implicating 
the smaller vessels of pia-mater and brain, and two of decided inflam- 
mation ; the transitions are gradual. 

Occasionally the cerebral arteries contained blood, their walls being 
flaccid ; and I thought this might be significant of impeded circulation. 
In a lad of 14 dying at end of invasion, the veins at vertex of brain were 
congested ; at the base the arteries contained fluid blood, and on tracing 
the middle cerebrals into the Sylvian fissure, signs of extravasation were 
seen around them, but no distinct coagula outside their walls ; and, as in 
some other examples, it was difficult to say if slight hccmorrhage had 
occurred or only transudation from some smaller vessels : the influence 
of gravity was not concerned. Punctate hsemorrhage in the convolutions 
and pinkish subarachnoid fluid, have been noted, v/ith this state of the 
arteries. 

Serous effusion was practically limited to the loose subarachnoid 
tissue at the vertex and sides of the brain, gravitating where plentiful 
towards the base : little was found in the arachnoidal sac : vascular 
congestion was present in 15 out of 20 instances and 8 times pronounced, 
when a sodden and semi-opaque condition of the arachnoid might co- 
exist. The quantity of transudation varied, and might be considerable : 
its aspect was usually yellowish and clear, sometimes reddish and very 
rarely turbid. The brain-substance was almost always wet and of di- 
minished consistence (especially in infants and the very young), the pia- 
mater somewhat soaked or loosened, and convolutions sometimes com- 
pressed. Marked serous effusion was most commonly seen at the close 
of pyrexia (at which time decease is frequent) and very seldom in an 
apyretic interval : its significance is probably not more considerable here 
than in other febrile disease. 



252 SPIRILLUM FEVER. 

Pallor as the prominent appearance was seen chiefly at the end of 
critical fall and during the later sequelar stages of the fever, or after 
copious haemorrhages : serous transudation and a wet condition of the 
brain usually co-existed. 

In a considerable proportion of the autopsies I witnessed, there was 
a pallid, wet, and shrunken state of the cerebral convolutions, combined 
with slight opacity of the arachnoid and pia-mater loose, pale or con- 
gested and wet. This aspect reminded me forcibly of the brain-changes 
noticed after typhus fever, in England. At two autopsies of complicated 
cases described by other observers, the brain was termed firm or very 
firm ; once with meningeal congestion, and once with serous effusion. 

Inflammation of the Brain (Meningitis). — This was distinctly mani- 
fested in 3 out of 5 7 autopsies : it was indicated about as often. 

An elderly woman with specific fever of uncertain duration, presented symptoms of 
pneumonia after what was probably the acme of attack : at autopsy a spot of localised 
inflammation and suppuration of the membranes and adjoining surface of the convo- 
lutions, was seen at the vertex of the left hemisphere ; there was some congestion and 
serous effusion around, and no other change of brain structure : here the cause of the 
meningitis remains unknown, in the following instance it was doubtless cerebral 
hcemorrhage. 

An old man, famine-immigrant, died on 5th day of the first apyretic interval, two 
days after the low fever and head-symptoms had rather quickly come on. — Vide Case 
XXIII., page 84. At autopsy, dura-mater unchanged. Arachnoid opaque only at 
seat of inflammation ; subarachnoid space not all over-distended : right side, dark extra- 
vasations along median fissure and over middle lobe at vertex, also to a less extent 
over frontal lobe, but behind none ; between these dark spots, purulent foci and 
infiltration, with softening around ; 1. side, similar but less wide extravasations in 
middle lobe and similar but more limited purulent infiltration : adhesions along 
middle line only, and no haemorrhage in cavity of arachnoid. Base of brain, mem- 
branes unchanged, but some sanious fluid in interpeduncular space ; haemorrhagic 
spots on under surface of frontal lobe, on contiguous surfaces of longitudinal fissure 
and in Sylvian fissure of right side. Substance of brain and ventricles : substance 
soft, wet ; puncta vascttlcsa on section ; r. lateral ventricle distended and its 
upper cerebral parietes ploughed up by a very large clot, in centre of which two 
firm rounded masses of fibrine: floor of ventricle unaltered, septum torn yet little 
blood in the 1. cavity. Cerebellum : hsemorrhagic spots and some opacity on upper 
surface and posterior border of both lobes ; substance unaltered, and 4th ventricle 
unaffected. Arteries of brain seemingly everywhere pervious; no atheroma: veins 
filled Medulla oblongata not chan ed : spinal cord and membranes, normal. No 
valvular disease : lungs inflated and pale ; apex, 1. lung the seat of small inflam- 
matory nodules, with pus in them ; no tubercles or adhesions : no splenic or renal 
infarcts : there were punctate haemorrhages in stomach and intestines. 

There was no history or sign of previous paralysis : the patient's daughter was 
admitted with him, and died after the relapse with thrombus of the left femoral vein: 
this coincidence of vascular phenomena is noteworthy. 

A woman, 50, admitted in a delirious state with specific fever of unknown dura- 
tion ; the day before death there was some dilatation of the left pupil and signs of 
left hemiplegia After death, pnei'monia was found and localised inflammation and 
suppuration beneath the arachnoid on the right side, at vertex of the hemisphere. 
These changes were quite isolated. 

Head symptoms commonly associated with chronic inflammation of 
the brain or membranes, may or may not be thus connected in this 
fever : — 

A woman of 35, suffering from chronic mania and in poor health, was 
seized in hospital with specific fever and died on the 4th day : nothing more than 
serfius effusion, with some congestion, was noticed in the brain. 

A man of 30, Aniline-immigrant, admitted just after invasion-attack, with debility 



ANATOMICAL LESIONS— BRAIN. 253 

and delirium passive, and resembling mania, underwent a relapse which was attended 
with exacerbation of the head- symptoms : 9 days afterwards he sank in a reduced 
state. The brain was somewhat congested on upper surface (arterial) with some 
evident opacity of arachnoid ; sanious serum one ounce : substance of brain normal ; 
clear serum, one drachm, in lateral ventricles, velum interpositum very pale. 

Cerebral Haemorrhage. — This serious lesion I thought best to de- 
scribe in connection with its symptoms, amongst the ' Complications ' 
of spirillum fever ; and would, therefore, refer to Chapter V. of this 
Section for the details, page 186. 

Pre-existing brain-disease. — Two instances were seen, which illustrate 
the little influence arterial degeneration and old lesion may have, in the 
production of febrile meningeal haemorrhage. In one (R, 55) there was 
an old clot in the corpus striatw7i and the cerebral arteries were athero- 
matous : some congestion was present, but no fresh haemorrhage : death 
early during invasion, and abundant blood-contamination. In the other 
(M., 60) also dying at invasion, the arteries were found atheromatous, 
yet not obstructed ; brain-substance soft and wet. Both these subjects 
were patients infected in hospital. Once a cavity in the left hemisphere 
was found in the body of a famine-immigrant (M., 30), dying in hospital 
6 days subsequent to defervescence : blood-spirillum not seen, the patient 
probably coming in too late. The cavity may have been remains of a 
clot, as there was reported a history of fits, and no sign of recent cerebral 
inflammation or fresh effusion. 

I have no minute memorandum on the state of the Spinal co?'d. 

Histological Notes. — The brain-tissues were examined whilst fresh, and 
with no re-agent besides acetic acid. The state of the blood-vessels 
leading directly to copious cerebral haemorrhage, was not ascertained ; 
but from the invariable absence of coarse arterial disease, it may be pre- 
sumed the lesions described below were present. These refer to com- 
moner phenomena amongst the casualties ; namely, first, to a state of 
coma or syncope (the two being connected), concurrent with irritation 
and accompanied by fatty degeneration of the capillaries and smaller 
arteries ; thrombus also sometimes being present : ex. i and 2. Next, 
a frequent state of the brain, in which head-symptoms are subsidiary, 
yet local lesion not absent : see examples 3 and 4. Lastly, a condition 
nearer to pure exhaustion ; ex. 5 and 6. The instances here quoted — 
six in number— were not selected, and are by no means exhaustive. 

I. M., 30, Mussulman weaver, admitted on 71 h day of illness, t. 103°, p. 114, 
many spirilla in the blood ; the symptoms those of low fever, no delirium. Next day 
a pseudo-crisis, with copious sweats and much depression, no headache, conjunctivae 
injected and yellow : on the following day pyrexia increased, headache and local 
symptoms generally slight. I marked the case as typical of specific pyrexia with 
debility ; the blood swarmed with spirilla in clusters ; a few hours before death, the 
man became unconscious and restless, skin supple, pupils of normal size and sluggish, 
breathing 40 and shallow, no sterlor, the state syncopic, pulse thready. At the 
autopsy, lungs pale and collapsed, characteristic lesion of heart, liver, kidney and 
spleen. There was congestion and serous effusion of the brain, exteriorly, slight 
opacity of arachnoid ; interior of brain pallid and rather soft, suspected extravasation 
in some convolutions of the Sylvian fissure. Microscopic examination— no hsemorrhage 
found and two specimens from the suspected spots showed nothing abnormal, a third, 
however, displayed much fatty degeneration of the walls of vessels and also of tissues 
immediately around them ; in a other place were seen accumulations of bright par- 
ticles in the coats of small vessels, no obstruction of the lumen or impacted contents 



2 54 SPIRILLUM FEVER. 

visible. Curiously, in the first preparation a living Filaria was present, apparently 
not derived from outside ; it was shorter and thicker than the Fil. sanguinis hominis 
of Lewis, dimensions y^so i"- ^y -^ in., tail acute pointed. The blood of the corpse 
still showed many clusters of spirilla. 

2. M., 24, also a weaver and admitted on 8th day of invasion, a similar low type 
of fever of the icteroid form ; there was a copious erruption of red spots, hsemorrhagic 
and mixed, conjunctivse injected and ecchymosed, pupils contracted and equal. He 
soon became semi-conscious and moaned, respirations 40, shallow and chiefly 
abdominal, and the nostrils worked. Next day a brief remission and high rise of 
temp, and death : a few hours previously I noted the skin becoming moist, 
he was quite unconscious, yet restless, the left arm and leg being less moved than the 
right, their tone remaining, and left side of face a little distorted ; eyes less suffused, 
pupils contracted. The blood was brownish, thin and imperfectly setting ; red discs 
not much altered, several pale granule-cells and some with oil in them ; a few 
spirilla seen, languid, and a few free granules. This was doubtless the commence- 
ment of crisis. At autopsy, the anatomical lesions were numerous and characteristic, 
including marked diphtheritic enteritis. There was much superficial cerebral con- 
gestion with extensive subarachnoid haemorrhage, and a spot of suspected extravasation 
in the superior peduncles of the cerebellum. Microscopic examination — at a blood- 
stained spot on superficies of cerebral convolution : nerve-tubules and ganglion-ce'l 
fibrils not visible, their place being taken by a quantity of granular matter ; blood- 
vessels in great part unchanged, but some are dilated and others contain bright 
granules of large size, resembling fatty particles ; besides, there are appearances of 
fatty degeneration of the vessels and tissue around ; the fatty matter has a yellowish 
tint, but is not to be confounded with debris of red-blood discs. Case referred to 
as No. LXXXV. Chap. V,, and below. 

From the above data I infer that the cerebral hgemorrhage in spirillum 
fever, may be attended with fatty degeneration of the smaller vessels. 
In the two following examples there was an absence of haemorrhage, and 
during life only subordinate head-symptoms ; yet, appearances indicate 
that the brain suffers like, if not equally, as other organs of the body during 
this infection ; and the datum is important. The last examples reveal 
. less advanced change, such as doubtless is common in severe cases of 
fever ; prominent local lesion (probably of similar nature) being found in 
other organs. 

3. M., 22; death on 7th day, with high temp. See Case XVI., page 75. 
Autopsy after l\ hours. Congestion of membranes, no haemorrhage or opacity, 
dark blood in cerebral arteries, brain-substance rather soft and wet, convolu- 
tions shrunken and pia-mater loose ; floor of 4th ventricle streaked with large 
veins. In blood at death no spirilla found, but some large granule-cells, not fatty, 
Micr. ex. of floor of ventricle towards upper end : there are strea s or stains 
not seen in other parts, extending below the surface, and still deeper small 
vascular spots are visible, especially on the 1. side at upper end, near a dark nucleus 
of origin of a cranial nerve {? par vaguni) ; no alteration of consistence. The 
prominent change here is the accumulation of white cells in the perivascular spaces, 
which is sometimes so large as to resemble extravasation and distinctly encroach on 
the nerve-tissue ; the cells are uniform and clear : none of the large granule-cor- 
puscles of the blood are here visible. In some places there seems to be thickening of 
the walls of the larger vessels, with smaller accumulations of round cells between 
their layers : whether this be a proliferation of connective-tissue corpuscles, or (more 
likely) a gathering of wandered cells from the blood, may be questioillaries or small 
apparently unchanged. There is no fatty degeneration of the capillaries or small 
arteries : the white-cell exudation seems to be connected with venous radicules. 

My figures show a state of the brain-tissue, which might be termed leucocytic 
inflammation, extravasation or thrombus- format ion ; and the site of lesion may have 
been connected with the depressed circulatory and respiratory symptoms, noted before 
death. 



ANATOMICAL LESIONS— THE LUNGS. 255 

4. M., 25. d. 6th day? with low temp. See Case LXXXIV., Chap. V. 
Autopsy after i^ hour. Congestion of membranes, sub-serous effusion, shrink- 
ing of convokitions, brain-substance unaltered ; two veins seen on floor of 4th 
ventricle, hardly abnormal in aspect. Mic. ex. of this spot — no morbid 
change around the clot-filled veins ; ^ below medium furrow was a larger vessel 
containing a clot, and around this spot the brain-substance was studded with 
many corpora amylacea of different sizes, some being in clusters ; blood-vessels 
seemingly unchanged, and no white-cell infiltration ; nerve-tissue probably un- 
changed. Corp. amyl. were not seen beneath the lining membrane of ventricle. \s 
the patient had been ill only 6 days and showed no head-ymptoms at the last, it is 
probable these amyloid bodies had no connection with his illness : the thrombi were 
doubtless associated with the contaminated state of the blood. 

5. M.; 34, d. on 15th day. Case LXXXIII. Gastric hsemorrhage. Autopsy 
after 4 hours. Some congestion and turbid effusion ; brain-substance rather wet 
and soft, no increased vascularity ; floor of 4th ventricle streaked and stained a 
little. Mic. ex. of the part ; there are several distinct haemorrhagic spots in 
the floor of the ventricle, and a few are found at | to \ in. beneath the surface ; 
here, too, some vessels are distended with blood without being diseased ; amongst 
their contents is a large amount of clumpy protoplasmic matter which resists the action 
of acetic acid and is like that elsewhere found in the blood ; white cells here few. 

6. M. , 23, d. on 9th day, temp, not high, moribund on admission ; many 
spirilla in the blood. At autopsy intense pulmonary congestion with apoplexy, 
splenic infarct, vascular patches in the intestines : much meningeal congestion, brain- 
substance slightly softened, pallid within ; suspected extravasation in cms cerebri. 
Minute examination of this spot, just above the locus niger ; there is some softening 
and staining of the tissue, vessels at various depths distended and of bright red hue ; 
actual extravasation not seen. It is likely that emboli were present : spirilla not 
visible within the vessels : they are always most difficult to see ia unstained specimens. 

2. The Lungs. — On account of their exceeding vascularity and elas- 
ticity, combined with scantiness of parenchyma, the lungs at autopsy 
are apt to vary extremely in volume, aspect and weight, even when 
disease is not suspected ; and as in spirillum fever no specific pulmonary 
changes have been recognisable, the usual record of post-mortem ap- 
pearances necessarily seems somewhat vague. The larynx was rarely 
examined, there hardly ever being symptoms referable to this part. 

The mean normal weight of either lung, has been estimated at 7, 14 
and 21 ozs. ; as such a wide range interferes with much particular in- 
ference in disease, it would be worth while studying the conditions leading 
to variation of post-mortem lung-weights. 

In 74 autopsies the lungs were regarded as being in a quasi-normal 
state 8 or 10 times, and this oftenest in deaths during the pyrexial stages. 

The entire lung on either side was pale and inflated, or pale and 
collapsed, 21 times, of which 17 deaths in febrile stages ; this is a note- 
worthy circumstance, even if it be assumed that the conditions im- 
mediately preceding decease are chiefly concerned : of the patients' 
symptoms at the agony there are seldom any records, but two examples 
are given below. A certain degree of congestion of the lung tissue 
(behind) and of the bronchial mucous membrane, with a varying amount 
of serous exudation (usually scanty) was commonly present, and some- 
times lobular solidification, especially in deaths during pyrexia ; but the 
general bloodless aspect of the lungs most impressed me, as being signi- 
ficant of impeded pulmonary circulation from altered quality of the 
blood. 

The expanded or collapsed state seen upon opening the chest is 
explicable in the usual manner ; persistent lung-inflation, independent 



256 • SPIRILLUM FEVER. 

of adhesions (very rare here), indicates impaired elasticity and to all 
appearance may be rapidly induced : it was seen oftenest and late (viz. 
chiefly in deaths towards close of invasion-attack) ; and in still later 
deaths (viz. at critical fall), was succeeded by the congested condition. 

Partial paleness, with collapse or inflation, was found in many of the 
remaining inspections, when other more manifest changes were present : 
lobular collapse, especially, is apt to be overlooked or misinterpreted. 

M., 22 (student), dying in the height of fever at 12.45 noon ; at II AM. the chief 
symptom was cardiac weakness, the pulse being hardly perceptible and uncountably 
frequent : no cough or dyspnoea, but respirations 70 per minute and very 
shallow (chiefly abdominal) ; the belly full, tense and very tender in the hypochon- 
dria ; at 12.30, it is reported 'became suddenly insensible, respiration greatly 
embarrassed and gasping; he moans loudly.' 3f hours after death the lungs 
were found to be pale, not collapsing, everywhel-e inflated and crepitant ; 
no hypostatic congestion, bronchial mucous membrane reddish only : no 
adhesions ; there were pale clots in the heart's cavities : weight of both lungs in this 
lad, 200ZS. Case XVI., Chap. III. 

M., 25, dying at reputed 5th day of fever, presented 6 hours before death a 
peculia'r state of depression : moans, yet is quite rational, breathing 50 very shallow, 
pulse 140, very soft ; he is recumbent but restless and turns on side, with knees 
drawn up : dyspnoea or urgent breathing, with full and tender belly, are the most 
prominent signs. i^^ hours after death, the lungs were pale and collapsed, 
and greatly compressed by the enormous liver which projected to level of 3rd 
costal cartilage on r. side ; diaphragm pushed up by distended stomach and enlarged 
spleen on 1. side : lungs nearly void of air and blood, pallid and as if emphysematous 
in general, with collapsed areas of purple hue, depressed, solidified and sinking in 
water, most extensive at posterior borders : several sub-pleural hsemorrhagic spots : 
lungs weigh R. 12 and L. 11 ozs. ; both alike in aspect. Death 15 hours after 
admission, when the blood was crammed with spirilla ; both the young men 
engaged in this autopsy became infected, and one died. Case LXXXIV. Chap. V. 

A similar condition of the lungs is frequent at death supervening 
upon that form of cerebral hemorrhage, which occurs in spirillum fever ; 
thus, in the instances narrated above, after excluding one of localised 
pneumonia, the lungs were either healthy-looking, or pale and inflated 
or collapsed ; and in the two cases where vascular engorgement was co- 
present, it is described as very marked and defined lobular congestion at 
the back part or as disseminated pulmonary apoplexy in small patches : 
in all these cases the weight of the lungs was light, the means being 
8-9 ozs. each. 

Congestion. — As the prominent condition was noted 13 times, chiefly 
limited to the febrile periods when the pneumonia begins, which is so 
often developed in the succeeding apyretic intervals. The lungs may 
be but moderately congested after death in high fever with insensibility : 
commonly it is the bases and back part which are most implicated, and 
the form and degree of vascular turgescence are as variable here as in 
the brain and other viscera. Instead of being diffused, it may be limited 
to a collection of lobules and so resemble lobular collapse, inflammation 
(early stage) or apoplexy, the state of congestion preceding or supervening 
upon each of these conditions. True hypostatic congestion was com- 
paratively unusual in the brief spirillum fever, being chiefly noted in the 
typhus-like cases occurring amongst Mussulman weavers and the more 
destitute : in such instances, the anterior part of the lungs might be in 
a state of collapse ; and on the other hand the hypostatic congestion be 



ANATOMICAL LESIONS — THE LUNGS. 257 

attended with pulmonary apoplexy, which would account for the slight 
haemoptysis sometimes noted during life. 

M., set. 23, a miserable-looking subject, admitted in a moribund state at the end of 
invasion-attack : many aggregated spirilla in the rather thick blood. Hypostatic 
congestion of both lungs and hsemorrhagic patches in both, at posterior patt ; bron- 
chial inucous membrane intensely injected and tubes filled with frothy, red serum. 
Pyrexia not high ; dyspnoea the most prominent symptom. There were infarcts in 
the spleen and minute haemorrhages in the brain and intestinal canal : jaundice was 
present. 

Pneumonia : Pleuro-pneumohia and Pleurisy. — These topics have 
been considered in connection with their symptoms under the heading 
of 'Complications' (Chapter V. of this Section, page 201); 

As instances of some ultimate lung-changes, I add here memoranda 
of two cases not verified microscopically, but almost certainly belonging 
to the spirillar series. 

Gangrene of the lung. M., 30, a recent famine-immigrant, admitted with a 
histoiy of relapsing fever and d}ing 10 days afteirwards. There was double basic 
pneumonia at the stage of suppuration, and a large gangirenous cavity on the right 
side : other viscera little changed in aspect. 

M., 27, admitted at height of the epidemic in a low state and jaundiced, underwent 
a relapse during which an anal abscess formed ; diarrhoea ahd symptoms comparable 
to phthisis ensued, and he died a month later. Both lungs were adherent, the left 
congested ; the right, in its upper lobe contained a large cavity filled with pus and 
having sloughy walls : liver large and fatty, the other organs little changed. 

The following cases illustrate a state of the lung best regarded, I 
should think, as acute oedema. 

M., ait. 46, in good condition, died the day after cessation of a well-marked 
relapse ; the temp, subsiding to loo°-5 in the interim, but promptly rising to 103° 
a few hours before decease : there was then low delirium, shallow, troubled respi- 
ration of 50 per minute, universal moist sounds and impaired resonance. Lungs 
inflated but pale, corrugated at apices but free of deposit ; pallid on section but 
peculiarly frothy, there being a universal diffusion of serum and minute air bubbles. 
Weights 14I (right) and 13 ozs. Heart contracted, left side quite empty, valves and 
substance healthy looking: cerebral congestion, splenic infarcts and a large flabby 
liver : jaundice. 

M., set. 40, died in 36 hours at the crisis of first attack (last t. noted 95°), respi- 
ration gasping as in asthma but not asthmatic, and compared in my notes to that of 
cardiac embolism : spirilla in the blood at first swarming, then few with some large 
fatty and endothelial cells. Lungs collapsed ahd substahce generally dty, but base of 
left lung infiltrated with frothy liquid, as in capillary bronchitis, yet without increased 
vascularity; the tissue floats deep in water; weights 18 ozs. (right) and 15 ozs. 
Heart (9 ozs.), right side contains a large, firm, decolorised coagulum extending into 
the pulmonary arteries to their end ; left side contains a small black clot only : kidnies 
showed early granulation. 

Hsemorrhage. — Occurrihg towards or at the close of primary fever, 
pulmonary haemorrhage assumes one or both of two forms, at least ; and 
in either, general cohgestioti of the lung may be present or absent. In 
pulmonary apoplexy the lungs have been found pale and inflated, whilst 
both were studded throughout with patches (apoplectic) in size from a 
pea to a peach ; no inflammation : co-existing petechiae in the anterior 
mediastinum, and larger effusions elsewhere. In 2 other cases, there 
was congestion of the lower and back part of the lungs accompanied 
by apoplectic consolidation 

s 



258 SPIRILLUM FEVER. 

In the petechioid or sub-pleural form, similar hemorrhages were 
always found elsewhere in the body, so that it may be said the lungs 
(highly vascular as they are) are not peculiarly predisposed to sanguine- 
ous effusion ; the common site was the surface of the lower lobes ; con- 
gestion if present, was hypostatic. An instance may be appended of the 
four in my list : — 

M., 24, suffering from the typhus-like form of spirillum fever, died during the 
^rs\. perturbatio critica (last t. 1 05° -8). R. lung intensely gorged with black blood 
(hypostatic) ; pieces float deeply and crepitate somewhat, the tint brightens on ex- 
posure, there are sub-pleural hsemorrhagic spots at the back of the lower lobe, weight 
200ZF. : left lung, in a similar condition, weight iSozs. ; in front the lungs are col- 
lapsed; no pulmonary apoplexy: there were hzemorrhages in the brain and else- 
where. 

It is a striking circumstance that ' tubercle ' in any form, state or site, 
was never noted in the whole series of 74 autopsies. 

Histological Note. — The following observation refers to that localised 
collapse of lung-tissue, which has been above mentioned : it is instruc- 
tive. 

M., 25, died soon after admission, with symptoms of urgent dyspnoea: many 
spirilla in the blood. Lungs pale and collapsed, and so greatly compressed by the 
projecting abdominal viscera, as to be nearly void of air and blood: emphysematous 
in general, they show depressed and purple-hued areas of solidified and heavier tissue, 
most extensive at middle of posterior border. Also sub-pleural petechiae. Micr. ex. 
The consolidated tissue is dry and solidified in an extent not defined as lobules, but 
interspersed with aerated patches in which the air-vesicles seem only small in size : 
no extravasation of blood, but walls of vesicles deeply congested and in parts en- 
croaching on the cavity: even here there is little less blood, and the idea imparted is 
that of thrombus in the pulmonary capillaries. White cells not increased ; there are 
some rounded collections of oil granules (besides some free), which correspond to the 
large fatty cells seen in the blood : spirilla not visible, and cause of embolism or 
thrombus not clearly made out. The chief points here, are the intense congestion of 
the solidified areas and also of the surrounding lung-tissue, with no extravasated 
blood and no cell-production of inflammatory aspect. 

The Heart. — A marked change in aspect of the heart whether transi- 
tory or structural was by no means invariably noted, and the brief de- 
scriptions of this organ contained in my records chiefly refer to size, 
appearance and arrangement of the blood-clots found in auricles and 
right ventricle : it is probable that alterations in the heart-musde were 
overlooked, yet they seem not so frequent as might be anticipated. 
Recent endocardiac or valvular disease, in direct connection with the 
fever was not detected : the sub-serous petechiae were but examples of a 
widely-distributed change, and here, as elsewhere, inflammation was seen 
in connection with the hccmorrhage as perhaps the most characteristic 
event of this disease. Besides occasional pallor, a friable consistence of 
the thicker muscular walls might be noted ; and the organ commonly 
appeared to be large from distension of its flabby parietes. It even 
proved to be heavier than usual, especially at advanced stages of the 
fever ; its weight being often entered as 9-1 1 ozs., and that not in elderly 
subjects. 

Upon a few occasions (7), the heart appeared so little altered that 
the term ' healthy ' was applied ; they all related to deaths during febrile 
periods, chiefly towards the close. 



ANATOMICAL LESIONS — THE HEART. 259 

Blood-clots within the organ commonly attracted attention ; very 
seldom was the heart empty, and then it might have been accidentally 
deprived of its contents, especially when it happened that these were in 
a diffluent condition. Clots of varied aspect are the chief entries 48 times 
(65 p. c. of all autopsies) : in at least one-quarter of these cases, the clot 
was nearly or wholly limited to the right side, or in near two-thirds if the 
critical periods and apyretic intervals of sickness be alone considered : 
when present on both sides of the heart, those in the right cavities were 
almost invariably larger, paler and more adherent : clots limited altogether 
to the left auricle or ventricle were never seen. These data would be 
useful were the conditions known under which blood collects in the 
heart or is detained, coagulates and becomes partly decolorised ; I 
have not attempted to elicit these conditions, and only observe that the 
hour after death when the autopsy was made did hot seem to influence 
the aspect and disposition of blood-clots. Thus, the mean interval was 
7 hours for both series of large, pale clots and no clots, and even a more or 
less fluid state of the blood might be present after an interval twice as long 
as this ; hence neither coagulation nor decolorisation is a.n invariable 
post-mortem phenomenon. The moi^e striking isolatioh and retention of 
blood-fibrin did not appear to follow any one mode of death, or vigorous 
or feeble action of the heart (as indicated by aspect of the heart-muscle), 
or visible state of the blood as related or not to stage of fever alone, ansemia 
or the reverse, malarious cachexia, results of haemorrhage, differences of 
sex and age, or finally to the conjoined state of the pulmonary organs, 
as for example pneumonia, in 14 cases of which with clots more or less 
blanched on the right side, coagula were nearly or wholly absent on the 
left 7 times. 

The various aspects of the contents of auricle or ventricle may be 
arranged as follows: — i. Blood wholly fluid (usually dark and most 
abundant on r. side) or mingled with small clots, black or pallid and 
non-adherent. 

2. Coagtila either uniformly dark and loose, or pale in interior and 
loose, or with pallid exterior surface and adherent. 

3. Decolorised masses of varied hue, consistence and volume, more 
or less adherent in ventricle or auricular appendage, and nearly always 
limited to the r. side. 

Illustrations are as follows : — 

F., 35, caught fever in hospital and died on 4th day, last temp. 104°: a little clear 
serum in pericardium ; right cavities filled with a large, pale and adherent clot, 
which extended into the pulmonary artery ; left auricle was also filled with a pallid, 
less adherent clot, the left ventricle contained a small, dark, loose coagultim limited 
to its cavity : heart-muscle and valves healthy looking: weight of organ 7 ozs^: lungs 
of normal aspect and volume, somewhat congested posteriorly. The patient was 
emaciated and probably died of exhaustion due to blood-contaminatioh and pyrexia ; 
the above appearances are almost typical. 

M., 25, died on reputed 5th day of invasion-attack: clear serum in pericardium, r. 
side of heart flaccid (now), 1. side firm ; dark clots oh both sides, looSely formed and 
non-adherent (blood still partly fluid) : heart substance firm, red. Some sub-serous 
petechiae: the man had jaundice. Lungs pale, collapsed and greatly compressed by 
thrusting up of the diaphragm : autopsy l^ hrs. after death. 

M. , 60, died in stage of semi-collapse at close of invasion-attack : many spirilla 
still in the blood: clear serum I oz. in pericardium, a large, pale, adherent clot in 
r. cavities passing into pulmonary arteries ; a similar but larger and longer clot in 1, 

s 2 



26o SPIRILLUM FEVER. 

cavities, also adherent and extending a considerable distance within the aorta : sub- 
stance and valves healthy, weight i2ozs. Lungs congested, but otherwise healthy, 
weights 24 and iSozs. In another man of 60 dying during pyrexia, a large, pale 
and adherent clot, extending into the aorta, was found in the left ventricle ; here 
was atheroma of the aorta and ossification of the coronary arteries : lungs healthy 
looking. 

Small quantities of serum, clear, seldom turbid, yellowish even when 
no jaundice apparent, were frequently found in the pericardial sac. 

Cardiac Haemorrhages. — These were limited to the sub-serous tissue, 
and almost exclusively to the sub-pericardial : they were petechial in 
aspect and hardly ever attended with signs of irritation : they were found 
after death occurring at the close of first attack, and almost always con- 
temporaneously with petechiae elsewhere. Their usual site was near the 
base of the heart, front or back, but they were also seen beneath the 
parietal layer of the pericardium. 

Illustrations are the following : — 

F. , 30, hospital-nurse, characteristically affected with fever of typhus-type. Peri- 
cardium nearly empty: a few hjemorrhagic spots beneath the parietal layer of the sac, 
and others beneath the visceral layer over the base of the heart at the back, where 
some are of considerable size : no sub-endocardial haemorrhage, but spots in the 
brain, lungs, kidnies, intestinal canal and skin. There were blood clots on the r. 
side of the heart (pale on their outer surface): lung inflated, congested behind. 

M., 32, died immediately after the critical fall (first attack), seemingly from ex- 
haustion, after prolonged death agony: large black clots were found in both right 
cavities and in the left auricle, 1. ventricle contracted : numerous bright-red, hsemor- 
rhagic spots over anterior surface of the heart, small and superficial, no pericardial 
effusion or opacity. Lungs everywhere crepitant, inflate d : some bronchitis and 
behind congestion: no other petechise noticed, but at the perturbatio critica there had 
occurred copious and repeated epistaxis. 

Hsemorrhagic Pericarditis. — This event was rare in Bombay, for only 
one autopsy was available of this fatal complication. See ' Complica- 
tions ' : Case LXXVII, page 208. 

M., 30, washerman, admitted near close of invasion, very ill, being highly jaun- 
diced and delirious: blood-spirilla numerous, large, and with rather a sluggish move- 
ment; the critical fall gradual, seeming convalescence established on the loth day 
of apyrexia, when a well-defined relapse took place, lasting seven days and ending 
with sudden fall of t. and death (spirilla numerous just before): the pulse failed 40 
hours prior to decease. Autopsy 2\ hours afterwards. Body emaciated, rigor mortis 
present, tissues stained yellow, blood semi-fluid and dark-coloured. Head— much 
dark, grumous blood in arachnoidal sac, chiefly on 1. side, no trace of inflammation 
or arterial obstruction, except a small, pale nodule felt in a communicating artery, 
but not obstructing its channel: brain congested, substance firm, healthy; weight 34^ 
ozs. Chest — Heart: 2 ozs. of bloody fluid in pericardial sac, both serous layers highly 
inflamed, covered with villous lymph (readily scraped oft) and marked with patches 
of haemorrhage ; heart contracted, muscular substance pale ; a small partly de- 
colorised clot in r. side, 1. ventricle more firmly closed, but containing a scanty pale 
clot: weight of organ 7j ozs. Lungs: collapsed: structure healthy; weights 8f (r. ) 
and 7 ozs. Abdomen — no fluid in peritoneum. Liver: normal size, surface smooth, 
aspect dark, structure congested yet of normal appearance, weight 2 lbs. i4|ozs. 
Spleen: enlarged, capsule thickened in one or two places, surface mottled and 
beneath the paler parts were infarcted masses in the interior: pulp generally some- 
what indurated and having diffused throughout a large number of pale red masses ; 
the more superficial of these had a deep yellow colour and were well-defined: those 
exceeding i inch in diameter were softening in the centre : there were also hemor- 
rhagic patches throughout the spleen pulp: weight 14 ozs. or nearly three times the 
normal. Kidnies: size normal, capsule easily separated, surface mottled yellow and 



ANATOMICAL LESIONS— THE HEART. 26 1 

red from hjemorrliagic stains ; on section, structure firm and as if infiltrated with 
some yellowish deposit: weights 3| (r. ) and 3^ ozs. Intestinal canal — small intestine: 
congestive and hsemorrhagic spots in the mucous membrane which had concentrated 
around Peyer's patches, especially at one spot about a foot above the ileo-csecal valve ; 
no ulceration ; higher up ihe valvulm conniventes were of deep hsemorrhagic colour, 
but this hue gradually subsided as ihs jejunum was approached. Large intestines: 
mucous membrane of deep leaden hue, especially in the csecum. Mesenteric glands 
nowhere particularly enlarged. (From notes by Mr. Sukharam Arjun). It seemed 
to me that the hsemorrhage into the arachnoid was of some days' standing, or at 
least gradually effused ; that into the pericardium appeared to be more recent : there 
was no defined deposit in the kidnies : the condition of Peyer's patches was this — 
raised, granular in aspect, defined and of deep blood hue ; the mucous membrane 
around for some inches being highly congested and blood-stained. Total duration of 
illness 21 days (possibly 3 or 4 days longer) ; time between convalescence or onset of 
relapse and death 7 days ; highest temp, in relapse 103°, quickest pulse 126, no 
special symptoms noted till vomiting and collapse at the end. The temperature and 
pulse chart is not peculiarly different from many of ordinary relapsing fever. 

Organic disease of the heart was seldom found in this series of 
autopsies. There is one instance of an adult man dying towards the 
end of a first attack of icterus type, when some thin fine bands of old 
adhesion and a milk-white patch were noticed in the pericardium : 
numerous petechiae in lungs and intestines : kidnies enlarged and mottled, 
probably fatty. 

M., 30, died at the first critical fall, of double pneumonia ; on admission 4 days 
previously a loud systolic murmur was heard, most distinct at mid-sternum and ensi- 
form cartilage ; there was also dyspnoea and palpitation, these symptoms, with pain, 
being estimated as of 15 years' duiation. After death the mitral valve was found 
thickened, opaque and narrowing its orifice ; there were pale, adherent clots in the 
cavities and large vessels on each side of the heart : both lungs were hepatised in 
their lower lobes. 

Histological Notes. — There is only a general accordance between the 
results of naked-eye and minute scrutiny of the heart-muscle ; and I 
find its pale, friable condition is not necessarily associated with such 
fatty degeneration, as was not unnaturally assumed to be present at some 
of the autopsies. 14 examinations were made, of which 9 in deaths 
during invasion, i at first interval, 2 at the relapse, i at second interval and 
I at sequelar stage. 

Of the first 9, the organ was apparently and really unimpaired in 
structure in 2 ; whence it is evident that death (and even prompt death) 
at this time, may take place without evident lesion of the heart. In 7 
there, was some change, but seldom considerable and never extreme. 
This change might be regarded as a granular degeneration of the 
muscular fibres extending from the position of their central nuclei, in 
the longitudinal direction ; and being often attended with pigmentary 
accumulations. Neither in this stage of fever nor any succeeding one 
(whether febrile or non-febrile) did I meet with genume fatty degenera- 
tion of the heart-muscle ; the sole exception referring to the case of an 
old man (set. 60) dying at the sequel, and whose other organs were fatty. 
In another man of 60 (the remaining patients were young adults or 
children), the coronary arteries were atheromatous and the left cavities 
contained large pale and adherent clots, so that the probability of a feeble 
heart seemed evident ; yet central pigmentary degeneration of some 



262 SPIRILLUM FEVER. 

muscular fibres, was the chief lesion found. This patient was admitted 
for chronic rheumatism, acquired infection and died in hospital, on 5th 
day of attack : there were very scanty signs of fat in the renal cells. 
Other instances are the following, the same method of examination 
being adopted : portions of the left ventricle the selected parts, and acids, 
alkali and ether being alone used as re-agents. 

F., 30, d. near end of irivasion. There were many petechial skin-spots, and some 
beneath both pericardial layers ; muscular substance of heart pale and soft (autopsy 
after 6 hours). Mic. ex. the fibres look coarse, yet they clear up on the addition of 
acetic acid, excepting some rows of yellow granules of different dimensions and form, 
which are situated chiefly between the fibres, but also in their interior: in the former 
case they seem to belong to the capillaries, and in the latter to be connected with the 
nuclei of the fibres, though sometimes found at their exterior. These granules do not 
resemble fat, and do not run together : they are placed at both ends of the long 
axis of the nucleus, gradually dwindling in amount as they recede in a longitudinal 
direction. This appearance was the ordinary one, and at first was mistaken for a 
fatty change ; it soon however became evident that that view was not correct. See 
Plate 11, Fig, R. 

M., 22, d. about the same time as the above, and probably from the same in- 
fection. Autopsy 3I hours after death. Muscular substance of heart red and firm : ex- 
amined after being in spirit for a few hours, the fibres seemed friable, had almost 
lost their transverse strise and readily split up ; they looked as if converted into 
fibrous tissue, or affected by a waxy change ; there was very little fat and few 
granules, colour rather paler than usual. On the addition of acetic acid all cleared 
up, the fibrils still retaining some longitudinal markings: granules and fat very 
scanty. Here the change was regarded as one of fibroid degeneration, and it con- 
trasted strongly with that described above ; being neither granular nor fatty. This 
patient seemed to die of cardiac debility, there was no suspicion of syphilis: the 
fibres did not show a tendency to separate transversely. Weight of heart 7 ozs. 

M., 25, died on reputed 6th day of invasion: {Typhus biliosus), autopsy after \\ 
hours. Sub-serous petechise outside the heart ; substance firm, red ; weight of organ 
8 ozs. After action of spirit for three days ; fibres rather firm and friable, splitting 
longitudinally and fibrillse readily separating in this direction ; sarcolemma indistinct: 
transverse division of the fibres not prominent ; strise very clear, though coarse- 
looking ; no fat, fibroqs tissues distinct. On the addition of acetic acid all clears up 
except some central rows of granules which are placed at either end of some of the 
nuclei, running in the length of the fibre: these granules vary in amount in different 
fibres, they do not resemble fat and may possibly sometimes arise by proliferation of 
the nuclei, but not always ; for some rows of particles lie at a distance from the 
nuclei. The change is like that first named above. 

In a man dying during first apyretic Interval, the heart-muscle being described as 
reddish and soft, the fibres were found very clear and so the stride ; yet there was a 
wide prevalence of central pigmentary degeneration. In a wqman dying at the close 
of the first relapse, the heart seemed healthy, and the fibres though coarse-looking, 
displayed the striae very clearly in most cases: and in another case, where the heart- 
muscle was pallid, granular degeneration of the fibrils was alone found. In a young 
man dying after the relapse, the muscular fibres of the heart appeared to be hardly 
changed ; some yellow granules were seen aroiind their nuclei. 

Aortic erosion.— \xvs,i2LT\z&'s, like the following may have been oyerlooked. M., 24, 
d. on 9th day (? acme) of invasion-attack, symptoms those of typhus biliosus. The 
blood at the last contained a few spirilla and several pale granular cells, some with 
fat in them. Limited cerebral hsemorrhage, kidneys albuminoid and fatty, spleen 
small, liver large and pale ; there was a distinct granular (diphtheritic) exudation in 
the mucous membrane of the ileum (lower end) and caecum— no ulceration: the small 
cerebral vessels at site of haemorrhage contained fatty granules, and were irregularly 
distended, but no embolus or thrombus was made out. The aorta showed just 
above the semilunar valves a few bright-red spots, which with a pocket lens were 
found to be excoriations of the inner membrane covered with a thin, granular layer ; 
and all down the main aortic trunk there was found a delicate interrupted layer of 



ANATOMICAL LESIONS— THE LIVJER. 263 

pale, granular material. Atheroma not present in this young subject. Mic. ex. the 
aortic erosion was depressed on the surface ; section of the vessel (hardened in 
chromic acid) showed the whitish, softened appearance to extend through the middle 
coat a- far as the outer: nothing more than abundance of fat was seen in this spot, 
but elsewhere the deposit was found to inclose also flattened endothelial scales ; and 
from the abdominal aon a a specimen was obtained displaying such scales loaded 
with oil globules, and readily to be detached from the lining membrane. Hence the 
idea that sometimes the fatty endothelium seen in living blood during and just after 
pyrexia, may be derived from the vascular endothelia proliferating and degenerating 
under specific blood-irritation. The diphtheritic diathesis in this case was, however, 
peculiar ; and I did not notice similar a pearances again. 

The Abdominal Cavity. — The cavity of the peritoneal seldom con- 
tained an excessive quantity of liquid, serosity not being much augmented, 
even when the liver and spleen were greatly implicated, or the sub-serous 
vessels in parts distended to rupture. When the blood is unusually 
diffluent (as occurs in ansemic and deeply jaundiced subjects), with other 
evidence of impeded circulation in the form of petechise, there may be 
an increase of yellow-tinted serum. 

Opacity, adhesions old or recent, the presence of lymph and hy- 
persemia were extremely unusual, and always limited and traceable to 
incidental cause and connection. A sodden aspect was rare, and 
tubercle never seen. 

Sub-serous haemorrhages were not uncommon over the viscera, in 
omenta and on the parietes ; and when abundant, may extend to the 
subjacent fibrous muscular and glandular tissues. Extensive extravasa- 
tion was seen only in the diaphragm and its crura, and in the right rectus 
abdominis muscle above. 

In general, the peritoneum seems to be less liable to lesion in 
spirillum fever, than any of the other great serous membranes. 

The muscular walls of abdomen were rarely implicated to a marked 
degree ; softening of the recti near the pubes was not recorded. 

The Liver. — Like the lungs, the highly vascular liver is capable of 
assuming much variety of aspect within quasi-normal limits, and to this 
also conduces its superadded portal and biliary systems of vessels ; 
hence in a paroxysmal fever such as the spirillar, its appearance differs 
at different dates, and from varying special implication, sometimes also 
in cases of similar duration and intensity. In this infection the blood- 
circulation is especially implicated ; and as by vessels the liver is closely 
associated with the spleen and stomach, it will be useful to consider 
the chief abdominal changes together, after dealing with each group 
separately. The mean normal weight of the liver in adult Natives of 
India may be estimated at 38 to 45 ozs. avoir. ; the organ is probably 
larger, proportionately to body-weight, than in Europeans : changes due 
to stimulating diet and intemperance, are much less frequent, but, 
on the other hand, malarious influence is a constant disturbing item un- 
known in Europe. The following data should be considered along with 
those furnished in Chapter III. sub voce. 

In 4 of 74 autopsies (5 '4 per cent.) the liver seemed normal ; of 
these two dated as sequelse, a third also several days after fever, and the 
fourth very early in first febrile attack. From this summary it is likely 
that some morbid change was either imminent or subsiding, and that 



264 " SPIRILLUM FEVER. 

the term ' normal ' is not strictly applicable here : see also below. En- 
largement was the most prominent condition in one-half the in- 
spections, but very seldom noted as the sole change. When the en- 
largement was pronounced, the liver exceeded 3 lbs. (48 ozs.) in 
weight ; it was then associated most often with a pale or mottled aspect 
(24 in 46 inspections) or with congestion of the organ (16 in 46), and 
commonly with a somewhat diminished consistence. Where the enlarge- 
ment was slight the liver weighed under 3 lbs. (in adults) congestion 
was here the ordinary accompaniment (11 in 20 inspections) or some- 
times a pale or mottled aspect (6 in 20). The maximum weight measured 
was 6 lbs. 8 ozs. in a man of 25 dying on 32nd day after an invasion- 
attack with jaundice and pneumonia, the liver was in the state of nut- 
meg-congestion, and there was a spleen of 5 lbs. (ague-cake) ; here the 
excessive enlargement was incidental to a connection with prior 
malarious influence and intemperance ; the minimum weight measured 
Avas 8 ozs. in an infant of 7 months, dying towards end of first febrile 
attack (spleen 2^ ozs.) Increase of volume was nearly twice as frequent 
in autopsies of fevered patients, as in those dying during non-febrile 
periods (60 and 33 p. c. respectively) ; and enlargement conjoined with 
other change, was even more preponderating. 

In cases at Bombay resembling the so-called typhus biliosus, the size 
of the liver was not different to the average ; indication of acute atrophy 
was so rare, -that only one instance occurred of the liver being below the 
mean weight during fever (2 lbs. 4 ozs., death in the first relapse), patient 
a man of 50. There does not appear to be any anatomical difference 
between this form of spirillum fever, and the ordinary severe kind, so 
far as regards the state of the liver. 

Pallor and mottling. — A general or partial paleness of the liver, was 
one of the most striking features at autopsy ; 1 7 times it was the most 
prominent character, and much oftener was witnessed a minor degree. 
There are shades of transition in all these morbid appearances, which 
need not be separately enumerated. Commonly the liver was enlarged as 
well as pale, seldom much congested and sometimes even bloodless in 
aspect : the hue was yellowish-grey, rarely brown, and though the 
changes here indicated pertain mainly to fatty degeneration, there was 
not seen that translucency and perfect smoothness belonging to the fatty 
liver in chronic disease. The entire organ may be thus affected, or one 
lobe more than another, or parts and sections of any : in the latter case, 
there ensues a mottling of the natural or artificial surface, and the pale 
patches sometimes seem tumefied. Fatty changes are probably the rule, 
though not perceptible to the untramed eye when partial, slight and 
diffused : they early attend parenchymatous inflammation. The sub- 
stance of the liver is less firm than normal, easily torn, and not display- 
ing with clearness the swollen lobules. The aspect of lardaceous disease 
was practically never noted ; and in no instance that I remember was 
there any induration, general or partial, of the liver-substance. 

In a comparatively small group of cases, the liver whilst enlarged 
and palish was of deeper yellow tint, flabby consistence, somewhat 
nodulated on the surface j and, on close inspection, the interlobular 
tissue seemed lax and dark, whilst the lobules became more defined and 
prominent, and the whole aspect resembled that of incipient cirrhosis. 



ANATOMICAL LESIONS THE LIVER. 265 

All the patients were male Mussulmans, generally from N. India, 
malarious subjects, and certainly the majority not drunkards. 

The connection of the two series here distinguished, is not obvious : 
probably their differences depend chiefly upon vascular changes, since 
no uniformity of tissue-lesion was apparent in the quasi-cirrhotic group 
(see below). 

The signs of chronic interstitial hepatitis amongst the entire number 
of autopsies, at Bombay, were never met with in even mild degree ; and 
this feature strongly contrasts with experience in Europe, where true 
cirrhosis is comparatively frequent. 

Congestion. — This was entered as the prominent condition in some 
instances not minutely described ; being sometimes specialised as portal 
or hepatic, but commonly repletion of both sets of vessels was under- 
stood. I have occasionally remarked a highly turgid state of the portal 
vein and its branches ; as, for example, in a man of 30, dying on iifth 
day of first relapse with cerebral haemorrhage, the whole organ being of 
enormous size, firm and of uniform aspect. The spleen was also very 
large, and free from mottling. Congestion is noted oftenest immediately 
after cessation of fever, or a Uttle later. ISIinor degrees were common, 
being of the passive form and probably connected with impeded circula- 
tion through the lungs and heart ; but in no uncomplicated casualty was 
there any approach to the nutmeg-aspect. Considering the extent to 
which the liver is implicated during spirillum infection, it is remarkable 
how seldom there could, at any time, be said to be a state of active con- 
gestion : possibly this precedes the parenchymatous inflammation, and 
if so its duration is brief, or its persistence incompatible with swelling of 
the hepatic cells. 

Diffused hepatitis as an attendant on spirillum fever must be very 
rare, notwithstanding the seeming urgency of local s>Tnptoms during 
height of pyrexia ; and the following is the only instance met with, to 
which this term would be applicable. The clinical history was necessarily 
defective, and no microscopic examination of the tissues was made. 

Case CI. — M., 14, admitted on reputed 5th day of specific fever (blood highly 
charged with spirilla), died seven hours afterwards in a very low state : no jaundice 
or petechise. Liver : very large for a lad (55 ozs.) actively congested, yellow-red in 
colour and mottled with large, pale patches found on section to extend deeply, and 
the like to be disseminated thro ghout, all being of irregular size and form, ill- 
defined and often suiTOunded by a vascular zone ; these patches were not apparently 
due to deposit, but rather to acute fatty degeneration of large portions of the liver 
gland ; gall bladder contained daik, viscid bile, no obstruction to ducts. Spleen 
II ozs., dark, firm and containing pale patches (so-called infarcts) similar to those found 
in the liver : kidnies congested. There was yellow fluid in the peritoneal sac ; no 
general peritonitis but the largely exposed upper surface of the liver (both right and 
left lobes) was smeared over with a little soft lymph ; this was valid evidence of 
serous inflammation, attending the parenchymatous, and hence of a general hepatitis. 

Acute abscess of the liver, whether single, multiple or metastatic, 
was never traced directly to the spirillar infection ; and, in this respect, 
experience at Bombay seems to have been peculiar. Hepatic abscess 
concurrent with the fever, was alluded to in Chapter Y. : see Case XC. 

The only form of hsemorrhage seen in connection with the liver, was 
in the form of sub-serous petechia, of which a large collection was once 



266 SPIRILLUM FEVER. 

noted upon the left lobe ; similar extravasations being found elsewhere 
in the peritoneum. 

The state of the Gall bladder and aspect of the bile appeared not to 
maintain any constant relation to liver-change ; departures from normal 
range being most rarely observed in either. 

Histological Notes. — The minute structural changes which I have 
seen, consist chiefly of cloudy swelling, and pigmentary or fatty trans- 
formation of the gland -cells ; the result being enlargement of the 
individual lobules of the liver, and hence of the entire organ. A much 
less frequent change, conducing also to the same end, is the produc- 
tion of leucocytes in the connective tissue connecting the lobules. 
The blood-vessels rarely were changed in aspect, and alterations of the 
bile-ducts were not noted. Free crystalline bodies were very rare. The 
tissues were examined in fresh state, and with simplest re-agents. 

It is probable none of these appearances, in the abstract, is peculiar 
to the spirillum fever : here, as in other fevers, early enlargement of 
the hepatic cells is attended with increase of their nuclei, often two and 
sometimes three, becoming visible on the addition of acetic acid. The 
degree of change was often remarkable, and some varieties are noted 
below. 

So far as I know, the extremely localised cell-degeneration sometimes 
evident, may be peculiar to this infection ; and it would indicate stasis 
of circulation in the finer branches of the portal vein. 

As to course of morbid alterations, there is, earliest, enlargement of 
the liver with uniform or disseminated pallor, and friable consistence ; 
all of which quickly supervene on the pyrexia, and are most pronounced 
in the first attack. At this time there is granular turgescence of the 
gland-cells, probably general, and the interlobular connective tissue is 
only seldom implicated (viz. 3 times in 16 special scrutinies) ; fatty 
transformation of the cell-substance is yet scarce. With cessation of 
pyrexia the turgid condition subsides, or it passes into the state of fatty 
metamorphosis, which I have found to be commonly present in 
casualties at post-invasion periods, whether or not accompanied by 
cloudy swelling of the cells. Recurrence of pyrexia entails repetition of 
enlargement (though to less amount), and gland-cell alterations. Finally 
the organ tends to resume its normal dimensions, but traces of cell- 
lesion may long persist. 

In 21 examples the relation of changes to stage of disease, was as 
follows — Invasion-period, great alterations, granular or hyperplastic 3 ; 
less pronounced, granular and fatty 6, hardly perceptible 2, total 
instances 11. First interval, some degree of pigmentary, granular or 
fatty change 2, little or none i, total 3. First relapse, fatty degenera- 
tion 2. Second interval some fatty change i, or none i. Sequelar 
stage, much fatty degeneration i, pallor of cells i. Pyrexia of un- 
certain date, much fatty change i. As a rule, the least apparent 
alteration occurred either before fever has lasted 3 or 4 days, or 10 
days or more after it has ceased ; but variations arise from both severity 
and complication of the spirilla pyrexia, and uncertainty of patients' 
reckoning. 

Although my enquiries have shown that the liver suffers in Remit- 
tent fever somewhat similarly, and that there may be nothing absolutely 



ANATOMICAL LESIONS — THE LIVER. 26/ 

peculiar here to the spirillum disease ; yet for future reference, par- 
ticulars are subjoined. 

Invasion attack. — An infant of 7 months was infected by its mother in hospital 
and died on 7th day. The liver vi^eighed 8 ozs., was of deep maroon colour and firm 
in consistence : the hepatic cells contained coarse granules, and vei-y little oil. 

A destitute woman get. 29, died on reputed 4th day (cerebral haemorrhage). The 
liver was large, but seemingly normal ; hepatic cells very distinct in all parts, and fat 
not abundant. 

A lad set. 22, died at the acme, jaundice slight. Liver 52 ozs., congested, firm, of 
uniform palish tint, surface smooth, sectional aspect unchanged, bile in gall-bladder 
of pale yellow hue : the hepatic cells seemed small and angular, they were filled with 
dark granular matter, and showed bright yellow particles (bile), no free oil ; some 
cells were shrunken and some empty ; on addition of acetic acid, there was a general 
clearing up, all the cells displayed a few minute oil globules, their nuclei distinct ; 
hyperplasia of connective tissue not noticed. These appearances are unusual in 
a liver so much enlarged ; possibly some concomitant change was overlooked. 
Case XVI. 

F.>, 30, died at the acme, jaundice marked. Liver 621 ozs., rounded, mottled, 
firm, pallid on section, granular when torn : hepatic cells affected with granular and 
slight fatty changes, no free leucocytes. The gall-bladder and ducts contained 
dark-green bile, no obstruction. Case XIII. 

F., 35, was seized in hospital and died on 4th day. Liver 44 ozs., and reported 
as simply congested : on closer examination I found pale patches disseminated 
throughout, and in these alone the signs of incipient fatty transformation. This 
example is instructive. The partial and seemingly irregular distribution of fatty 
changes, of considerable degree, was well shown in the case of another woman ; 
some of the cells contained also clumps of biliary matter ; the organ was large and of 
softish consistence. 

Hyperplasia of connective and no cirrhotic aspect. — M. , 25., typhus biliostis, death 
on reputed 6th day. Liver 73 ozs., pallid, with paler patches on the surface barely 
visible, edges not thickened, surface smooth and shining ; sectional surface uniform, 
lobules indistinct, some hepatic congestion ; a little viscid dark-green bile in the 
gall-bladder, no occlusion of ducts. Hepatic cells filled with albuminous granules, of 
brown tint, little oil or pigment, nuclei unchanged ; the slight fatty change not 
limited to exterior of lobules but disseminated in patches. Connective tissue in some 
portal canals decidedly overgrown, and this change doubtless contributed to the 
great enlargement of the organ : blood-vessels and ducts not materially altered. 

Cirrhotic aspect and no hyperplasia. — M., 30, death at close from pyrexia and 
exhaustion. Liver enormous (74 ozs.) congested, of deep orange-brown tint, nodu- 
lated on the surface uniformly ; everywhei-e the lobules are collected in masses, vary- 
ing in size from a pea to a walnut, deep-tinted and the sub-lobular (hepatic) veins 
repleted : the interlobular connective tissue appears scanty, loose, and of dark-grey 
colour ; peritoneal coat not opaque ; general consistence of liver soft and flabby. 
Autopsy 8 hours after death. The connective tissue has a coarse and indistinctly 
striated aspect ; on the additi' n of acetic acid very few cell-nuclei are seen, either 
oval or round, and there is no fat ; no cell-accumulation is visible in the coats of the 
vessels, or any gelatinous thickening ; the connective tissue may be attenuated, and 
the great enlargement appears due to vascular turgescence and distension of the gland- 
cells themselves. These are filled with fine granules and bright pigment particles, 
nuclei distinct ; oil globules detected in a few only of the cells. 

Pseudo-cirrhosis and no hyperplasia. — M.,34, died at close of pyrexia, probably the 
first attack, of gastric hsemorrhage. Liver (after the haemorrhage) hardly enla'-ged, 
41 ozs., pale-yellow, very firm, tough, slightly nodular on surface; on section a 
granular aspect, as of isolated groups of lobules, uniform ; left lobe very small, no 
opacity of serous coat, or adhesions. At first sight, this looks like an early cirrhotic 
change, but the impression is not confirmed, for the interlobular connective tissue is 
lo' se and not increased in amount. Much dark-brown bile in the gall-bladder. The 
lobules seem compressed from distension ; there is very much fat ; hepatic cells are 
of bright yellow tint, highly granular, and their nuclei invisible, they are closely 
compacted and their outlines ate indistinct. On the addition of acetic acid the 



268 SPIRILLUM FEVER. 

amount of oil globules is seen to be large, the cell-nuclei appear ; there is no sign of 
cell proliferation, and the walls of the vessels are seemingly unchanged. 

These three last instances, with the following one, suffice to prove 
that a true cirrhotic change was not witnessed at Bombay as the result 
of the spirillar infection ; the appearances are certainly peculiar, and, I 
think, much elucidated by the last example above quoted. 

Of 3 deaths during first Interval, one or perhaps two are connected 
with the series just discussed. 

M., 40, died on second day after crisis with pneumonia. Liver 520ZS., surface pale 
yellow, mottled with red, and somewhat nodulated at the thin edges : on section, an 
appearance of yellowish distension of the lobules, with limiting vascularity and soft- 
ness of their investing connective tissue : consistence flabby ; autopsy 4 hours after 
death. The hepatic cells are filled with fine albuminous and pigment granules, their 
nuclei clear and very little oil visible : connective tissue seemingly unchanged, and 
no free leucocytes. 

M., 30, died on 7th day with jaundice and diarrhoea. Liver 57 ozs., pale,- soft, 
rounded edges : gall-bladder empty. The hepatic cells seemed small, many were 
converted into bags of oil, and in others was an accumulation of dark pigment : there 
were also free cells resembling leucocytes, with fibrous appendages, the appearance 
being that of connective-tissue overgrowth around. 

M., 10., death on loth day with pneumonia. Liver 23 ozs., noted as healthy- 
looking ; but on close inspection, faint pale patches were detected throughout the 
organ, being disposed in clumps and streaks, made visible with a lens and seemingly 
encroaching on the exterior of the lobules themselves. In these pale spots the 
gland-cells had undergone an extreme degree of fatty transformation : small-cell 
infiltration was not seen. This instance illustrates a late liver-change. 

In 2 deaths during first relapse, both of women, the liver once 
weighed 47 ozs., and was rather soft, there being diffused fatty change ; 
moderate in degree. Once the weight was 54 ozs., aspect pallid 
and consistence firm : amidst the gland-cells of normal appearance, 
there were scattered many others which had undergone an extreme 
fatty change. The notes of another case, M., 46, show the liver to have 
been very large and flabby, bile-ducts gorged, lobules indistinct, con- 
gestion portal : there was an appearance of glandular atrophy and no 
sign of interstitial growth. 

In 2 instances of death at second Interval (4th and 9th days 
respectively) the evidence of fatty transformation was less than above. 
I add another example — 

M.,30, dying, exhausted on 9th day. Liver rather large, mottled with pale 
patches which extend into the substance of the organ ; otherwise normal in aspect. 
To my surprise the cells in these pale patches had an unchanged aspect, clearing on 
the addition of acetic acid and showing no fat globules. This instance proves the 
converse of others, namely, that the appearance of fatty degeneration may be 
illusory, at late stages of fever : here the gland-cells seemed to be recovering (not 
reproduced \ wanting only some of their coloured bile-constituents. Such recovery 
may not ensue, as a longer deferred instance shows. 

M., 60, enfeebled, gradually sank two months after relapse. Liver 46 ozs., pale, 
firm, dry ; there was hepatic congestion. Extreme fatty degeneration of the cells 
throughout ; a condition not indicated to the unaided eye. 

The connection of liver-changes with varying aspect of the blood as 
regards both spirillum and new cell-forms, did not strike me as being 
apparent ; and, so far as I could judge, it was not peculiar. Morbid 
hepatic lesions in this disease, seem attributable chiefly to pyrogenctic 



ANATOMICAL LESIONS— THE SPLEEN. 269 

influences similar to those existing in some other specific fevers ; and if 
a special part be allotted to the visible blood-additions, it should, I 
think, be limited to explaining the remarkably defined extent of fre- 
quent degenerative lesions ; e.g. the disseminated pale patches of fatty 
changes, which in character are comparable to so-called ' infarctions ' of 
the spleen. The liver- infarcts may be secondary to the splenic. 

The Spleen. — That owing to malarious influence, this organ is 
habitually enlarged in a large proportion of the grown-up population 
of India, has been generally admitted ; yet within the range of my ex- 
perience in W. India, such a state of permanent hypertrophy is by no 
means universal, or even common. Hence I am disposed to place 
considerable reliance in the data furnished below, as evidence of spleen- 
changes during the spirillum disease ; and, in fact, these data seem to 
correspond fairly with those elicited in Europe, where malarious 
influence does not much prevail. 

Taking weight as a gauge of volume, the range in healthy adult 
Natives of W. India (Bombay and the Deccan in particular), was 
estimated at 5-12 ozs., or from ^-L_ to ^^0 of body- weight ; the lower 
figure being so much nearer the average, that it may be said the 
prevailing normal weight of the spleen is about 5-7 ozs., or near the 
mean for European residents, whose bulk, however, is ^ or ^ greater, 
and in whom the larger weights are practically wanting. Variations 
according to age are doubtless similar everywhere.^ 

Spleens of quasi-normal aspect. — Four of the 6 pertain to apyretic 
intervals, and are simply illustrations of the rapidity with which the 
spleen may resume much of its ordinary state after fever ; the other 2 
cases were the following : — 

M. , 50, weak, while in hospital with chronic bronchitis caught fever and died in 5 days ; 
fever not high or sustained, spirilla in the blood to the end. Spleen 6 ozs. and com- 
parable in aspect to a healthy kidney, its capsule smooth, pulp rather softened 
(report of officer in charge) : liver 42 ozs., pale and soft : autopsy made 12 hours after 
death. This case seems to show that until midway, at least, of a first febrile attack, 
the spleen may not be very sensibly enlarged. 

M.,22, dying at the critical fall. Spleen reported as unusually small {z\ ozs) : 
liver not enlarged (42 ozs. ) ; autopsy 5 hours after death. As it stands, this example 
may indicate the immediate subsidence of turgescence on cessation of pyrexia. 

Another instance of little enlargement Occurred in a lad of 7, dying of high fever 
on 7th day. Spleeti 2.\ ozs., or \ of liver-weight and not more thetn weight of a kid- 
ney in same subject. As a contrast, an infant of 7 months dyilig at a similar 
epoch, had a spleen of 2.\ ozs., or nearly ^ of liver- weight and moire than both kidneys 
together. 

Enlargement. — Was noted alone in 64 per cent, of the autopsies, or 
combined with other changes, in 76 p. c. Absolute increase varies with 
stage of fever, being greatest during fever and tending to subside after 
crisis : see the next Sub-section. Alterations concurring in a total of 

1 Useful general data for Bengal were supplied by Dr. S. C. Mackenzie, in the * Indian 
Medical Gazette,' July 1878: and some valuable statistics of body-changes in the famine- 
stricken by Dr. A. Porter in a Report on the Sanitary and Medical Aspects of the Famine 
in Madras 1876-7, issued under the superintendence of the Sanitary Commissioner, Mr. 
W. R. Cornish, C.I. E. At the Bombay hospitals it was seldom that the diminishing influence 
of starvation had to be allowed for, but the pomt was borne in mind ; and it is not un- 
likely the small dimensions of some infarcted spleens, were due to mal-nutrition of the 
patient. 



270 SPIRILLUM FEVER. 

55 examples were congestion 6 (chiefly during first attack) infarcts 7, 
softening 20 ; commonly the organ was turgid and dark-coloured, its 
edges rounded, capsule thin, tense and smooth, not easily torn off, and 
free from external adhesions. Incidental to conjoined old malarious 
disease were limited opacity and thickening of the capsule, uniform firm 
consistence, and generally prominence of the Malpighian bodies. Post- 
mortem softening being very likely to occur early in a tropical climate, 
not much stress can be laid upon this conjunction ; yet a decided dimi- 
nution of consistence was noted in 7 of 12 autopsies made under two 
hours after death. Enlarged spleens sometimes displayed pale specks 
and streaks scattered throughout the pulp ; the cut surface was often 
dry, and generally the dark blood-tint quickly became bright on ex- 
posure to air. 

Softening. — This change in some degree is probably constant, when 
considerable it was usually recorded without comment : the mean weight 
of 8 specimens was 9 ozs., and the mean time after death of necropsy 
6 hours. It seems unquestionable that the consistence of the spleen is 
sometimes greatly reduced during life, at least during the last period 
prior to decease. The softened organ is easily torn and its pulp may 
be almost pultaceous ; there is usually much congestion, possibly some 
extravasation ; the capsule was thinned. Though oftenest seen at close 
of invasion-attack, yet extreme softening was proportionately commoner 
at the succeeding interval. Even when not due to incipient decompo- 
sition, it may not always be of the same character, 

F., 44, died in a drowsy state at reputed 6th day of first attack ; hlood loaded 
with spirilla. Spleen 8 ozs., its pulp said to be seemingly disorganised: liver 40 ozs., 
congested ; there was acute fatty degeneration of the kidnies. Body much emaci- 
ated: autopsy 4 hours after death. 

Rupture of the spleen was never detected at Bombay. 

Splenitis and abscess were not seen as simple results of fever. In 
connection with infarcts, limited and scant perisplenitis was once noted 
(see below) ; and there are notes of a small softened infarct occurring in 
a child suffering from a recurrence of fever — nature unknown of first 
attack, with abscess in the shoulder : spirillar infection may have pre- 
ceded, but the great rareness of these acuter sequelar phenomena at 
Bombay, is in contrast with recorded experience at St. Petersburg and 
some other European cities. It occurred to me that possibly malarious 
induration of the spleen might render the organ indisposed to such 
changes. Metastatic abscesses and thrombosis of the splenic vein were 
not witnessed here. 

Infarcts. — These I find to be altered portions of the spleen-pulp, 
and as such they are usually comparable to the pale patches seen in the 
liver. Minor and rarer changes of the Malpighian bodies of the spleen 
are illustrated further on. 

The 14 instances alluded to in the Summary (equal to 20 p. c. of all 
autopsies), were of the more pronounced degree ; and if obscurer or 
incipient examples be included, the number of infarcted spleens would 
be nearly doubled. 

As contrasted with the parenchyma generally, these altered portions 
are, at first, somewhat swollen, of lighter reddish or yellowish semi- 
translucent hue and firmer in consistence ; their dimensions vary much, 



ANATOMICAL LESIONS — THE SPLEEN. 27I 

and so their number and form. In position they may be superficially 
placed, or deep-seated. At a later stage, their tint becomes lighter and 
more opaque, the margins more defined and consistence softer, especially 
in the centre. Appearances differ according to site ; thus, when deep- 
seated the spots are apt to be less defined, of irregular shape and redder 
hue ; whilst the superficially placed assume a pyramidal form (base out- 
ward), and are paler and sharply limited. I have found infarcts at the 
periphery alone, whence it is likely they are earliest formed there ; they 
were commonest at the edges of the organ. 

The detection of this pulp-change sometimes requires care, and upon 
several occasions no particular alteration in the cut surface of the spleen 
was noticed at once ; but after a few minutes' exposure to the air, a 
manifest difference appeared, and shortly the outlines of the changed 
parts became clearly visible. This is a point of some practical import- 
ance, and when desirable, I have had bodies re-opened for closer search, 
finding the spleen thus changed although apparently not so at first 
examination : hence a rule always to examine this organ a second time, 
if doubt existed as to the presence of infarcts. Slight dessication and 
the action of atmospheric oxygen, renders distinction of normal and 
changed pulp more apparent ; the altered portion becoming lighter and 
shrinking less : this difference may be seen even through the capsule of 
the spleen. 

Enlarged Malpighian bodies and delicate white streaks in the pulp 
may co-exist with infarcts ; and occasionally there were seen small 
patches intermediate in character. Apparent hsemorrhagic spots may 
co-exist, and when the changed area is well-defined, it may be surrounded 
by a zone of dark vascular shade ; this is oftenest seen around super- 
ficially placed infarcts. In them, too, the splenic capsule may be 
slightly thickened, and the serous coat at this spot dulled ; there being 
a distinct raising of the surface. At a later stage, there may be slight 
depression of the changed area. 

Infarcted spleens were commonly enlarged, yet not quite invariably 
or in equal proportion ; they were usually firm, but sometimes of dimi- 
nished consistence, and this independently of post-mortem softening. 

In 53 deaths occurring during febrile periods, manifest splenic 
degeneration of this kind was noted 1 1 times ; and amongst 2 1 deaths 
at apyretic intervals 3 times : when appears its connection with both 
specific pyrexia and decease. The mean age of these 14 patients was 
26 years, extremes 18 and 46. 

Other particulars are furnished in the following summaries of cases. 

M., 18, feverish and delirious, died a few hours after admission at reputed 5th 
day of invasion: the chief lesions were found n the blood (which was dark and co- 
agulated slowly, contained many large white corpuscles, protoplasmic masses and 
active spirilla) and in the spleen. This organ was large (g^- ozs. ) dark-hued, firm ; 
capsule smooth, thin, translucent and inadherent. On the outer convex surface an 
ovoid, pale-red patch, an inch across, surrounded by a darker purple zone and, on 
section, traceable for an inch and a quarter into the pulp, where it assumed a conical 
form, the base corresponding to the ovoid outline on the surface. Spleen-substance 
— the whole pulp was infiltrated with smaller pale-reddish masses of softish consis- 
tence, the lesser of which might be compared with enlarged Malpighian bodies, 
whilst others were like coarse granules or nodules. Speedily on exposure to air, other 
infarcts became visible along the edges and fissures of the organ being distinguished 



2/2 SPIRILLUM FEVER. 

by their opaque reddish tint: the capsule over these places was somewhat thickened. 
The liver was large and marked with pale patches on its convex surface. 

M., 46, admitted with his brother at close of invasion, underwent a typical first 
relapse and died just after its termination, pneumonia being apparently imminent, 
Of all organs the spleen was most changed in aspect, weight 20ozs., colour dark, 
consistence soft and lacerable, hue on section purplish: there were several pale, 
raised patches on the convex surface and borders, wjfiich were due to soft, pale-red 
infarcts, others being present in the interior of the organ: diameters half an inch to 
an inch, form cuboid or elongated. Liver large, yellow, flabby. 

M., 35, admitted in a dying state, possibly at end of relapse; the blood charged 
with spirilla. After death the signs of copious gastric haemorrhage. Spleen 240ZS., 
livid, firm, edges rounded, capsular nodules (old), no adhesions ; at first no light 
patches visible on the surface, but upon partial dessication they make their appearance 
and it becomes evident, on section, that the spleen pulp is not of uniform structure, 
there being large, palish-red areas disseminated throughout, oftenest, perhaps, near 
the centre or hilus ; these paler spots contrast slightly with the darker bluish pulp 
around, yet cannot be always traced to the surface, where also red patches are 
indicated ; no real discrepancy obtains here for the outlines are too indistinct to map 
out fully. These appearances would be explained by diffuse capillary haemorrhage 
(giving the dark hue to pulp), or by wide fatty degeneration (causing the paler 
aspect) ; since the more prominent surfaces on dessication correspond to the darker 
tinted pulp (the paler collapsing somewhat), there has been probably some inter- 
stitial haemorrhage yet no loose clots, of even small dimensions, can be picked out, 
and this idea therefore remains unverified. Liver pale, firm, not enlarged. Autopsy 
after 4 hours. 

With reference to parenchymatous extravasations, there are some 
other notes, one of which belongs to a case of cerebral and pericardial 
hsemorrhage, the statement reading that together with a large number of 
pale red infarcts (the more superficial having a deep yellow colour and 
being well defined) there were hsemoi-rhagic patches distributed through- 
out the splenic pulp. I also remarked that the larger pale spots in the 
spleen (i-i^ in. deep) were softening in the centre. Patient a male of 
30, dying at close of first relapse. Case LXXVII. 

Concurrence and likely connection between enlargement of the 
splenic Malpighian bodies and incipient infarction, was indicated in the 
following cases ; see also below. 

F-j SSj died towards close of first relapse. Spleen, double the usual size, livid, 
edges rounded, some pale patches on the surface ; pulp firm, deep purple, and 
studded with small white dots — Malpighian bodies ; these are as large as a pin's 
head and very prominent ; besides, corresponding to the pale patches seen under the 
capsule, is a similar pallid infiltration of the pulp reaching to the depth of I —I J 
inches. The patient was lately parturient, and infected in hospital. 

M., 14, died at invasion. Spleen 11 ozs., firm, dark, friable; capsule thin and 
showing through it a dotted aspect due to subjacent spots, probably large Malpighian 
bodies: there was also slight indications of pale patches, comparable to those existing 
in the liver. Spirilla in the blood of the corpse. 

After death from malarious fever these bodies are often distinct ■ 
and upon direct comparison, I once noted the malarious spleen (much 
enlarged) to differ from the spirillar, in being of firmer consistence, of 
greyer tint, uniform throughout, Malpighian bodies very clear and the 
fibrous capsule more readily torn off. 

The following is the only instance seen of perisplenitis. 

M., 20, died on 4th day of second Interval. Spleen 19^ ozs., there is recent 
lymph on the dark coloured surface, at the edges of a fissure ; there are visible also 
light patches which correspond to pale reddish masses occupying the pulp beneath 



ANATOMICAL LESIONS — THE SPLEEN. 273 

and rather firmer than it: the splenic parenchyma is of less dark hue than the 
surface, and rather soft. The infarcts are most distinct at the anterior border bf the 
spleen, where probably the circulation is most languid. Liver large, smooth, pale: 
pneumonia was present i 

Morbid histology of the Spleen. — My notes refer to the cell-constituents 
of the pulp ; fibrous structures and the blood-vessels when examined, 
furnishing little sign of departure from a quasi-normal state. 14 unse- 
lected specimens passed under notice, 8 of which pertained to the 
Invasion -attack, 3 to the first Interval, 2 to the first Relapse and i to 
an uncertain febrile date. 

The spleen of an aborted foetus was small, not congested and like 
a bit of kidney ; nothing peculiar was detected about it ; spirillum not 
found in the blood. 

Invasion-period — In a male infant and a lad of 7, the spleen weighed 
equally 2\ ozs., appeared healthy and showed no abnormal elements on 
minute scrutiny : in a man of 24 the spleen was actually and relatively 
smaller than usual (9 ozs. ; liver 61 ozs.), and the pulp was filled with cells 
which seemed to be simply multiplied. These 3 cases are evidence that 
the spleen may seem unchanged as regards its structural elements, in 
fatal cases of spirillum fever ; and the last one, at least, shows that this 
may be so when other organs are characteristically altered. The remain- 
ing 5 cases furnish testimony of a change in the spleen-pulp, comparable 
to that simultaneously occurring in parenchyma of liver and kidney : this 
demonstration was a novel one to me. 

F., 35, died on 4th day (contagion in hospital). Spleen 70ZS., dark, soft and 
friable: interspersed amongst the normal cell-elements were some oil globules, and 
-t- acetic acid a large number of fat globules appears, varying in size from the 
smallest imaginable to drops as large as a red disc ; they arise in the spleen -cells ; 
Malpighian bodies not affected. Date September 1877, and specimen marked 
' Acute fatty degeneration of spleen:' the same change was present in the liver and 
kidnies, which also were little Changed in general aspect. 

M., 35, d. 8 day. Spleen 16 ozs., friable ; amortgst the trabeculae and 
pulp are parts which have undergone as much fatty change as seen in the kid- 
nies, possibly on site of extravasated blood, yet the cells (nuclei and substance) are 
also implicated ; there are parts of the pulp less changed, the blood-vessels and 
trabeculae being unaltered. 

F., 30, d. same date. Spleen, 18 ozs., soft; acute fatty degeneration of pulp-cells 
is very distinct in places, their nuclei are invisible. 

M., 20, d. near end. Spleen 38^ ozs. dark, firm but friable, and having many 
small infarcts dispersed throughout the pulp: there are here numerous cells loaded 
with fat and some very large masses of fat granules, besides fine, free oily matter. 
Some large granule-cells were seen in the right cavities of the heart ; they may 
evidently come from the spleen. The blood was very thin and of pale brown hue ; 
it contained many spirilla. 

M., 25, d. near end. Spleen 36 ozs., turgid, rather soft (i^ hrs. after death) and 
containing many faint pale-red patches. Micr. ex. — Normal darker part of pulp. It is 
tougher and more flaccid ; fibrous structures distinct, pulp cells less crowf'ed and their 
fatty aspect less pronounced ; some fatty cells are still seen, -t- acetic, and large endo- 
thelial cells ; but their number is comparatively small, and degeneration slight. Pale 
patch in interior — many large cells with nuclei like those found in the blood ; ordinary 
leucocytes not so abundant, and there are transitions from these to the larger granule- 
cells, which hence may be hypertrophied and degenerated pulp-cells. + Acetic acid, 
the field mostly clears, the small cells swelling into a compact mass ; but there are 
places where extreme fatty degeneration is indicated (nuclei still visible) ; also fatty 
endothelium and occasionally large oval masses of oil are seen amidst unaffected 
tissue. The evidence of a fatty change, whether or not preceded bj cloudy swelling, 

T 



274 SPIRILLUM FEVER. 

in this infarcted area is decided ; the material here is paler, less translucent, turgid 
and friable, and the histological resemblance to pale patches in the liver is sufficiently 
close : infarcts, therefore, are areas of degeneration. 

Of the 3 instances dying in first interval, i detailed below shows a 
condition essentially belonging to the preceding pyrexial period ; i is 
the case of a man dying of liver-abscess just after the apparent termina- 
tion of invasion-attack (contagion in hospital), the spleen weighed i6 ozs., 
and my notes state that large granular, nucleated cells were seen in the 
pulp, such as are often found in the blood at critical fall. The last case 
is that of a girl dying of dysentery, eight days after a specific attack of 
uncertain date ; spleen-weight i^ ozs., and no peculiar appearances 
detected. 

M., 35, caught the fever in hospital and died in a sharp rebound ensuing imme- 
diately on the crisis. Spleen 19 ozs., turgid, dark and firm, no infarcts on first 
section, but afterwards indicated after exposure to air. Mic. ex. of a pale part 
preserved in alcohol: dense collections of small cells, most seem normal, others are 
larger and of granular aspect ; + acetic ; most clear up, but the large granule-cells 
remain for a time, finally clearing and not showing nuclei ; decided fatty degeneration 
was not apparent, and it would therefore seem that the first stage of infarction re- 
sembles the cloudy swelling of hepatic and renal cells, to which fatty transformation 
succeeds in the spleen, as elsewhere. 

The specimens from death in first Relapse (2) and at undetermined 
date (cerebral haemorrhage) (i), seemed to belong respectively to the 
series of no minute change of spleen-elements, of cloudy swelling or 
granular degeneration, and of incipient fatty degeneration of pulp-cells : 
in the first case numerous chains of vibrating particles were seen, re- 
sembling some visible in the blood taken before death. 

Upon review of this detailed series, 1 find that affected spleens are 
commonly of large size, and that the liver at the same time is also large ; 
both organs in 6 examples being simultaneously implicated : in 2 others, 
however, the liver alone was chiefly affected, the spleen in one being 
rather large but not diseased, and in the other still less enlarged yet 
decidedly diseased. This last case proves that in death from spirillum 
fever so early as the fourth day, the spleen (as other organs) may undergo 
prompt fatty degeneration with very little other visible change. Simple 
febrile enlargement of the spleen is due mainly to multiplication of the 
pulp-cells, vascular turgescence also contributing part. It is remarkable 
how rarely dark pigmentary degeneration of the spleen-cells, was noted 
at Bombay. 

The Kidnies. — Lesions of the renal secreting structure may be non- 
apparent, and in part obscured or simulated by incidental changes ; 
hence ordinary data have but a limited value. Another drawback 
arises from the undetermined amount of pre-existing kidney disease, 
likely to be found in the less temperate Native races ; this source of 
fallacy, however infrequent by comparison with European experience, 
has still to be borne in mind. 

The normal mean weight of each kidney in adults, is estimated at 3^ 
to 4 ozs. 

Quasi-normal aspect. — Under this indefinite term, some examples 
of minor organic change were doubtless included ; yet here is evidence 



ANATOMICAL LESIONS — THE KIDNIES. 275 

of but little visible alteration at stages, both febrile and non-febrile, 
during which these 10 instances equally occurred. 

Congestion : 26 examples. — This as a prominent character, was seen 
in deaths during pyrexia ; occasionally the organs were also enlarged, 
and sometimes in parts pallid ; attendant hcemorrhage was very rare. 
The degree of persistent congestion seldom amounted to active 
hyperaemia, such as is supposed to precede acute nephritis ; though a 
certain degree of vascular turgescence no doubt goes before and at- 
tends, the glandular degeneration described below. The weight of the 
kidnies was only slightly above mean, and considering the intensity 
of spirillar pyrexia, it is noteworthy how little hypercemic these organs 
have appeared ; specific fever is, however, of brief duration, and epi- 
thelial alterations may be quickly induced. 

Congestion is not said to be limited to either cortical or medullary 
substance : sometimes it was mainly hypostatic. 

Interstitial hgemorrhage was very rare. 

Acute parenchymatous nephritis was never met with, nor the diffused 
or disseminated suppuration (metastatic and local) mentioned as attend- 
ing severer cases of recurrent typhus in Europe. 

Pale and enlarged kidney : 33 examples inclusive (nearly 45 p. c. of 
all autopsies). — In frequency this change answers to the concurrent 
alterations in liver and spleen : it was found almost exclusively in 
deaths at the febrile acme and fall, arid early ensuing apyrexia, being 
rare before fever and congestion had existed for a certain time. The 
maximum weight of a kidney (the right being somewhat oftener the 
largest) was 6\ ozs., seen at both acme and fall ; the lightest specimen 
weighed 4 ozs. From my tables it appears that the increase of volume 
after invasion-attack is so marked, that the kidnies weigh more during 
the first apyretic interval than they do during the relapse, or even 
during the earlier days of invasion -attack : this fact is worthy of 
recollection. 

Consistence seldom so firm as natural, friable and flabby. 

The colour is described as pallid or pale yellow, distributed either 
uniformly or in patches over the surface of the kidnies ; stellate vascu- 
larity increasing the mottled aspect was not unusual. Upon section, 
the cortex and medulla are not distinct ; the secreting portion is en- 
larged, and sometimes of coarse aspect from the presence of vascular 
streaks and dots ; the pyramids compressed, striated and congested at 
their bases. The aspect of partially localised pale infiltration was not 
uncommon, and sometimes marked ; but distinct renal infarcts were 
never seen. 

The mucous membrane of the pelvis is congested, and occasionally 
the site of small haemorrhages. 

Capsule. — Thin and translucent, as a fule, commonly non-adherent, 
and sometimes even readily separated : at other times without thicken- 
ing, vascularity, or much opacity, the capsule was adherent, wholly or 
in part, and could not be removed without laceration of the glandular 
superficies. If not pertaining to pre-existing disease (which was never 
proven), this last condition would indicate irritation attendant upon 
degenerative chariges, answering to more occasional thickenings of the 
serous envelope of liver and spleen. The cellular coat of the kidney is 



276 SPIRILLUM FEVER. 

the seat of small extravasations, corresponding to the commoner sub- 
serous petechise. 

Illustrations accompany the histological memoranda. 

Instances of pre-existing kidney change are the following : — 

M., 40, died at the (first ?) critical fall. Kidnies 6 and 5^ ozs., much congested, 
flabby, capsules very thin and when separated bringing away renal tissue : substance 
coarse, studded with cysts. The left kidney was most affected, and showed signs of 
interstitial fibrosis, unquestionably of older date than this febrile attack ; a similar 
change was beginning on the right side. 

In a girl of 8, dying of femoral thrombosis just after the first relapse (her old 
father died about the same time of cerebral haemorrhage), the kidnies were pale and 
firm, capsule rather adherent ; some stellate mottling of the surface, but no disease 
apparent. There was a double ureter on right side, in connection with a narrow 
elongated organ. Urine not albuminous. 

Histological Notes. — I examined 26 specimens taken at different 
stages of the fever. The only lesion usually found is strictly comparable 
to that commonest in liver and spleen, consisting of a granular tumefac- 
tion of the parenchymatous or secreting cells, which is^ apt to end in 
fatty transformation of their contents and probable disintegration of 
structure. Not only do the renal cells exhibit this cloudy swelling 
with or without ensuing fatty degeneration, but they are also at first 
multiplied ; their nuclei becoming more numerous, like those of the 
hepatic cells. These changes sufificiently account for the pallor and 
enlargement of the kidnies above described ; in some degree and in 
some part of the cortical substance, they are probably invariable. 
According to my experience, the fatty transformation is somewhat 
less frequent in renal than in hepatic and splenic lesions ; cloudy 
swelling is at least as marked, being also more readily recognised in the 
broad uriniferous tubes. As regards the liver, quasi-physiological con- 
ditions may simulate incipient morbid changes ; the spleen is liable to 
prior malarious hypertrophy; and so the kidnies may have been damaged 
by previous nephritic disease, likely to entail lesions similar to the above. 
Hence the need of careful discrimination, when estimating the character 
of post-mortem appearances. 

A distinguishing feature of the fever-lesion at Bombay, was the 
general absence of concurrent interstitial cell-infiltration or fibroid 
thickening ; very few instances were noted of any change of the inter- 
tubular tissue and vessels, and this fact shows the rarity of comprehen- 
sive nephritic lesion in fatal spirillum fever at Bombay. Corresponding 
in such negative feature, was the seldom-changed aspect of the urine : 
see Chap. III. In Russian and German towns, renal implication is said 
to be frequent and pronounced \ hence a difference open to varied 
interpretation. 

Lesion according to Stages of Fever. — Invasion-attack : 15 speci- 
mens. Granular turgescence of the renal cells, was in some amount 
always present ; and in | of cases, fatty changes were also more or less 
clearly indicated. 

Examples. — M., 30, died of cerebral haemorrhage with specific infection. Kidnies 
large, congested, substance flabby and yellowish, capsule thin and somewhat adherent. 
The renarepithelium was coarse- looking, distending the tubes in many places, but the 
amount of oil present very scanty : Malpighian tufts rather large and wax-like, no 
fatty degeneration here. F., 35, died on 4th day, exhausted ; kidnies, like the other 



ANATOMICAL LESIONS — THE KIDNIES. 2/7 

organs, comparatively unchanged in aspect. Some congestion of inter-tubular veins, 
Malpighian tufts not distended, epithelium of tubes very coarse-looking and often 
much accumulated, no free oil : + acetic acid, the renal oils were wholly free 
from fat ; many small, elongated collections of minute oil-globules were seen between 
the tubes, in their walls or in the stroma itself ; Malpighian tufts not diseased. This 
appearance was not again seen outside the uriniferous tubes. 

F., 3d, death from fever. Kidnies large, capsule not adherent but congested and 
containing some petechiae ; substance congested and flabby, surface mottled with 
yellowish patches : on section, the cortical portion broad, of deep yellow tint, dotted 
and coarse-looking, petechiae in the pelvis. The uriniferous tubes were filled with 
granular cells, in which only traces of oil were present, the capillaries of Malpighian 
tufts unchanged, inter-tubular tissue unaltered : an occasional red disc was seen 
within the tubes. No fatty degeneration of other organs. A similar instance occurred 
about the same date, in which a distinctly pallid, friable and tumid part of the kidney 
proved to be wholly free fr m fatly changes : these examples showed how little de- 
pendence can be placed on mere appearances. 

Kidney at crisis. ^M., 32, famine-immigrant. Organs large, pale, mottled, firm, 
capsule not adherent; the most striking change is pallor, some intertubular congestion 
is noticeable in places. Renal epithelium very coarse and partly detached (autopsy i6i 
hrs. after death), its granular aspect uniform and not as if due to oily particles, Malpi- 
ghian tufts unchanged, blood-vessels in places distended : on addition of acetic acid, 
sometimes not a trace of oil, the cells clearing wholly, nuclei distinct and granular ; 
sometimes there are distinct granules and globules of oil to be seen in the tubes, but 
this is not common, and only a few of the tubes displayed incipient fatty transforma- 
tion: the greater number being rendered opaque and much distended with dark-brown, 
granular epithelium or masses of granules : a few oil globules were to be seen in the 
capillaries of some Malpighian tufts. 

Analysis of four examples belonging to the severest form of spirillum 
fever {typhus biliosus, death at acme of first attack), showed the kidnies 
to be larger than usual, pallid or mottled with blood-vessels, and flabby ; 
the cortical part pale, soft and seemingly fatty : the fibrous capsule thin, 
adherent twice over limited areas, and non-adherent twice ; petechiae in 
both groups. The histological changes in the cortex were as follows : 

Uriniferous tubes distended in parts, with hypertrophied epithelium of finely- 
granular, thickly clouded and brownish aspect, nucleus not visible ; twice the cells 
were so swollen and compressed as to have lost their contour, and become blended 
into an opaque granular mass, apt to become detached from the walls of the tubes. 
The appearances might be confined not only to certain tubuli iiriniferi but even to 
different lengths of the same tube ; and this feature is noteworthy, when taken in 
conjunction with a similar localised distribution of liver and spleen cell-changes. By 
such lateral expansion (not, so far as I saw, limited to flexuosities of the tubes) the 
adjoining blood-vessels become compressed, aud hence (as in the liver) the compara- 
tively bloodless aspect which conjoins with the tint of the cloudy swelling to impart a 
general pallor to aff^ected parts. On the addition of acetic acid, the clouded aspect 
disappeared wholly, cell-nuclei becoming apparent, except when the epithelium was 
converted into a uniform granular mass, in which alone globules of fat abounded. 
The Malpighian tufts were, at most, congested ; and the inter-tubular tissue not 
altered, except when the fibrous capsule of the organ was adherent. The last of the 
cases showed this. M., 25, dying soon after admission : kidnies large, pale (uni- 
formly), flabby, capsule thin and adherent at parts, a few petechiae in its substance. 
Mic. ex. — Cloudiness of the tubular epithelium, sometimes very marked, sometimes 
contents of the tubes have become detached : -f acetic all clears up, and there is no 
fatty degeneration : Malp. tufts clear and entire ; in some parts there is slight cell- 
proliferation of the inter-tubular connective, but no thickening of the matrix : the 
tubes vary in diameter. 

Two other instances of more pronounced kidney-disease merit 



2/8 SPIRILLUM FEVER. 

special notice ; both patients were admitted in a moribund condition, 
and the urine was not examined. 

F., 44, autopsy after 4 brs. Kidnies 5 ozs., firm, slightly granular and mottled, 
capsule thickened p,nd in part adherent ; cortex engorged, dotted with blood and en- 
croaching on the medulla. Blood loaded with quiescent spirilla. There is universal 
fatty degeneration of the renal epithelium, nuclei in walls of Malp. capsules loaded 
wi th fa t ; hsemorrhagic spots amidst the tubes, with much congestion (cortex). 
+ acetic, degree of fatty change extreme : the congestion is chiefly venous, and there 
is effusion of blood in the tubes themselves ; vessels of Malp. tufts partly covered with 
fat globules : probably there is also a new formation of fibrous tissue, for some free 
nuclei are seen interspersed amidst the glandular tissue. Heart normal ; pleural ad- 
hesions, but peritoneum healthy ; no dropsy : duration of fever reported at 5 days only. 

M., 30, d. 8th day. Kidnies 6A-7 ozs., congested, softened; int. surface uni- 
formly yellow, medullary pyramid indistinct, capsule firmly adherent. Renal epithe- 
lium coarse, dark and commonly in a state of fatty degeneration ; some of the tubes 
are of normal aspect, others much enlarged. Malp. tufts show fat globules in the 
walls of their capillaries ; -I- acetic this becomes more evident, and large drops of fat 
are seen within the cells and tubes, in certain parts. The liver and spleen furnished 
evidence of fatty change ; spirilla were common in the blood ; and my impression is 
that in this cage, if not in the preceding one, the morbid changes found may have 
been due solely to specific infection. 

First interval. — The dates of death ranged from i, to 7, 9 and 32 
days after the critical fall : pneumonia was always present : state of 
kidnies as follows : — ^Dimensions somewhat less, renal epithelium always 
granular and twice showing scanty, partial fatty changes. In the death 
just after the fall, the liver cells were granular and rather less fatty than 
the renal ; in the death on 7th day, the liver cells were very fatty in parts, 
and the renal less changed in this direction : in the two later cases 
the appearances were as if granular or albuminous degeneration were 
slowly subsiding (coarser granules, with less intumescence, being present) 
by absorption of the diffused intra-cellular material ; but the presence 
of pneumonic fever may be here concerned, since I find none of the 
renal changes under notice are peculiar to spirillum fever. 

First relapse. — Both the deaths were of females (ages 20 and 35), 
one taking place on the 4th day (fall commencing and cerebral haemor- 
rhage) and the other on the 5th day, specific fever still being high 
(splenic infarcts). It is remarkable that in both cases, the kidnies 
seemed only congested ; and on minute examination I found the renal 
epithelium in the first hardly altered, and in the other there were but 
scanty signs of granular and fatty change (the latter being limited to the 
Malp. tufts) : hence it might be inferred that the kidnies do not suffer 
much, in even well-marked first relapses. 

Second mterval. — In a man of 20 dying with incipient pneumonia on 4th day 
(splenic infarcts), the kidnies weighed about 3;V ozs. and were pale : most of the renal 
tubes were distended with highly granular epithelium, fat very scanty ; small collections 
of broken-down red discs in some capillaries. In a man of 30 dying exhausted on 
loth day, the kidnies were equally small, but not pallid : the renal epithelium looked 
coarse, but did not cont.iin fat. 

Sequel. — A man of 60 sank exhausted a fortnight after recurring attacks : kidnies 
4-5 ozs., smooth, pale, tinged with bile, capsule slightly adherent in parts: the renal 
epithelium had undergone extreme fatty degeneration and the capillaries of the Malp. 
tufts were sometimes affected: crystals of leucine and tyrosine amidst the tubes. The 
liver and heart also were fatty. 



ANATOMICAL LESIONS — THE STOMACH. 279 

Uncertain date. — A girl of 12 dying 10 days after cessation of fever (dysentery), 
had renal organs congested but otherwise normal : some of the uriniferous tubes were 
doubled in diameter by accumulation of granular epithelium ; the nuclei seemed multi- 
plied : no fatty matter. A man of 35 died at crisis of fever (cerebral haemorrhage) : 
kidnies 4 ozs. each, pallid, effusion of blood around apices of pyramids, capsule non- 
adherent : the renal epithelium had undergone an extreme degree of fatty change, and 
some arterial capillaries were affected ; there was venous inter^tubular hsemorrhage. 
In other cases of cerebral hsemorrhage neither kidnies nor heart M'ere fatty, and sub- 
jects were young. Adhesion of the renal capsule in some degree, was noted only 
6 times in these 26 autopsies. 

Uterine System. — Only this portion of the generative apparatus was 
scrutinised. 

F., 30, unmarried, death during invasion, with characteristic symptoms. Uterus 
healthy, mucous membrane pallid and no signs of hsemorrhage (there were petechise 
elsewhere). 

F., 35, was deliveied of a full-grown child about 10 days before fever came on ; 
she died towards the close of the relapse : no symptoms referrible to the womb. Uterus 
4 ozs., a little large from defective involution ; the cavity seemed also large, but was 
empty and the lining membrane healthy : so the ovaries and Fallopian tubes. (Mr. 
Bh, A.) 

In a woman of 20 who died during the relapse, the uterus was found to be healthy 
in aspect. 

The Intestinal Canal. — No anatomical details are available re- 
specting the mouth, fauces or pharynx ; nor are any histological notes 
yet prepared. 

Stomach. — 16 autopsies. Though not numerous, these were fairly 
representative, and they include two examples of black vomit. In the 
absence of lesion elsewhere, the mucous meixibrane alone of the stomach 
is alluded to, Palpable change of consistence was never seen (not even 
of the post-moftem variety) ; congestions were common, and seldom, I 
believe, wholly accidental ; haemorrhages certainly were peculiar : in- 
flammation and ulceration of the mucous membrane were rare and never 
pronounced. There being no sign of chronic or minuter lesion, the 
microscope was not applied to fresh specimens, and the preserved are 
as yet unexamined ; probably chronic stomachal lesions are rare in the 
comparatively abstemious Hindoo races. Briefly, in the vascular cha- 
racter of most post-mortem lesions there is an accordance here and in 
the remainder of the intestinal canal, with other organs of the body : the 
state of the blood itself being identical. 

It is proper to add that stimulant drugs and alcohol had been ad- 
ministered prior to decease, in most of the cases here analysed. 

Congestion : 10 instances. — Common in deaths during specific fever 
(8 in 11) J but found in later febrile complications, and as a sequel. 
When associated with blood-contamination it was present about the 
mid-region and towards the pyloric end of the stomach, and had not an 
accidental aspect ; sometimes it might be termed active ; haemorrhage 
was usual, and small erosions have been noticed in the same spots. 

A connection with epigastric symptoms during life seemed a,lwaya 
possible. 

Haemorrhage : 8 instances.— Also closely connected with the febrile 
state (7 in 11), and -not noticed as a sequel. The extravasations were 



280 SPIRILLUM FEVER, 

always small (petechioid), often in clusters and when limited, situated 
along the lesser curvature or towards the pylorus : their site was ap- 
parently the sub-mucous connective ; minute erosions were sometimes 
perceptible over them, and petechiae were always present in other parts 
of the body The instances of black vomit are not here included. 

Pallor : 5 instances. — Seen during both fever and intermission, and 
this fact sufficiently shows the contingent character of vascular changes 
here and in other parts of the body, as complications of spirillar infection. 
However, during actual pyrexia it is likely the mucous membrane is 
injected ; with the crisis it may become pallid, and it is probable that 
copious gastric haemorrhage then takes place : see below. 

Illustrative memoranda : — 

M., 22, died on 7th day of invasion. Stomach distendedj its mucous membrane 
congested to a pronounced pink hue : little intestinal congestion, liver and spleen 
congested. Autopsy after 3! hrs. 

F., 30, death at 8th day of invasion. The stomach distended ; sub-serous petechias; 
piucous membrane highly congested, and numerous sub-mucous extravasations of 
small size along the lesser curvature ; some viscid mucus streaked black with blood, 
coated the surface, and had been forced into the oesophagus ; hence had this patient 
Jived, a certain amount of ' black vomit ' might have appeared as a symptom during 
life (other patients have exhibited such a sign). Similar black mucus in the intes- 
tines. Autopsy after 6 hours. 

M., 34, died at perturbatio critica of invasion. There were localised congestions 
and small haemorrhages in the stomach and intestines. A case of ' bilious typhus. ' 

M., 35, died immediately after the critical fall, a sharp rebound intervening. 
Mucous membrane of stomach rugous and villous, of uniform deep pink colour ; no 
extravasation of blood here, a few petechia in the adjoining small intestine. Liver 
and spleen enlarged. (Mr. S. A.) Autopsy after 2 hours. 

M., 55, died during first interval, of cerebral haemorrhage and inflammation. 
Stomach distended with a green liquid, intensely Congested dnd marked with bailds of 
vivid punctate haemorrhage along the small curvature and towards the pylorus. Con- 
gestion and petechiae at lower end of small intestine. Liver large and pale ; spleen 
Ismail and dry. 

M., 22, died in the first relapse, with pneumonia. Great vascularity of mid-region 
pf the stomach, with haemorrhagic spots. There had been much epigastric pain and 
vomiting, at the last. 

M,, 30, died at close of close of first relapse, with cerebral haemorrhage. Stomach 
distended, several narrow streaks of haemorrhagic patches running lengthwise ; apparent 
erosion over some of the spots. Autopsy after 2 hours. 

M., 60, cachectic, died 42 days after last attack of fever. Along with fatty de- 
generation of heart, kidney and livpr, and a malarious spleen, the stgmachal mucous 
membrane was pallid, with red patches and longitudinal streaks, over which were 
numerous shallow erosions. Sequelar stage of fever. 

Black vomit.' — M,, 34, died ait first critical fall (t. 95°), autopsy I hour after 



• There are notes of two other fatal cases of fever, one having a history of a relapse 
and the other a stranger ; in both deep jaundice and the typhoid state : no vomiting in 
either. As the blood-spirillum was not seen, these instances are omitted from the text ; 
yet their symptoms and general character undoubtedly judicate their spirillar nature. 
Qastric hemorrhage in the remittents of Bombay, I never saw. M., 20, died during 
pyrexia (? secondary to relapse), the stomach (and intestines) contained a black, grumous 
liquid ; and there were small, soft coagula adhering to the pale mucous membrane. M., 
40, blackened mucus in the stomach, a group of dark spots qn the posterior surface below 
the lesser curvature, at the pyloric end a large group of bright pink spots, and at the ter- 
mination of the oesophagus longitudinal streaks (^ — i^in. long) of deep black extravasa- 
tions, which at their upper end merged into bright red spots (no change in the pharynx), 
over these the mucous membrane seemed about to slough : the intervening tissue was 
healthy-looking ; the lymphatic glands in connection large, dark and soft. No morbid 



ANATOMICAL LESIONS — THE INTESTINES. 28 1 

death. Stomach distended with more than 2 pints of a thin pitchy-black fluid ; on 
its evacuation, muc. membr. seen to be thrown into large rugse, surface pale all over, 
large veins not distended, and neither diffused congestion nor hsemorrhagic spots were 
more than indicated. Close scrutiny showed the entire absence of unusual vascularity 
or of any erosions of the surface ; but rather decided pallor, and the rugous state 
resembled that of most stomachs under contraction. Liver large and softish ; gall- 
bladder contained 2^ ozs. of glairy, yellow-tinted bile, quite diverse to the pitchy 
fluid. Small intestines also filled with a similar dark liquid, and no vascularity here. 
There had been copious hsematemesis a few hours before death. No infarcts in the 
spleen. See Case LXXXIL, page 213. 

M., 34, died at decline of fever of uncertain duration ; no vomiting before death. 
Stomach contained air and a pint of black, grumous fluid ; glairy discoloured mucus 
lines the interior surface ; muc. membr. seemingly intact, and nowhere congested : all 
coats of stomach pale, no thickening, and no dullness of serous covering. On scrutiny 
with a lens, I found the muc. membr. universally pale ; yet after gently scraping the 
surface very minute red puncta might almost everywhere be seen, most numerous at 
larger end and beginning of lesser curvature ; these had a stellated or blotchy aspect, 
and appeared to be placed beneath the unchanged epithelium. There were a few 
larger pink streaks, deep-seated. Upon pinching with forceps around these small 
dots, the specks became larger and deeper-tinted, and sometimes a minute quantity of 
blood exuded, slowly trickling away on the free surface, together with mucus also 
thus squeezed out of the stomach-follicles ; the source of the gastric haemorrhage 
during life being in this manner rendered obvious. Muc. membr. of small intestine 
was unchanged in aspect ; contents of the gut some blackish mucous and faeces : liver 
not enlarged, veiy pale ; much dark-brown bile in gall-bladder : spleen very large 
and infarcted. Case LXXXIIL 

The Pancreas was examined on a few occasions and fou